GW1-2021-04539_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 1 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
85 fL 106 ft' I
3002-A APR 2 9 2021 ft. rL
NC Well Contractor Certification Number
CSSI� � UTER CASING(for multi cased wells)OR(LINER(if a" 'licabte
Carolina Well Drilling ROM TO DIAMETER t THICKNES MATFRIAL
Irtt:,rl�;ation Pr000•-' � ft.
Company Name 0 ft. 47 61/8i : SDR21 PVC
16.INNER CASING OR TUBING't eothermal dosed-loop)
2.Well Construction Permit#: 21-53 FROM TO DIAMETER THICKNFS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL,
Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. rL in,
Industrial/Commercial DResidential Water Supply(shared) 18.`GROUT. ,
Irrl ation FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft' 20+ fc. Bentonite Pour 15 501b Bags
Monitoring ORecovery fL rt.
Injection Well:
fL rt.
Aquifer Recharge OGroundwater Remediation
19rSAND/GRAVELxI'ACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage fL fL
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) OTracer 20.1DRILLING LOG attach additional sheets if necessary)-'k,
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiVrock type, rain slm,etc.)
0 ft. 13 fL Brown Dirt/Rock
4.Date Well(s)Completed: 2-24-2021 Well ID# 13 rt' 200 ft' Blue Slate
5a.Well Location: ft ft.
Dustin Belk fc ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3511 Leonard Morgan Rd. Marshville 28103 ft. fL
Physical Address.City,and Zip ft. rG
Union 03-057-002E 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.53.872 N 80.21.784 Wc%
3-5-2021
6.Is(are)the well(s)&Permanent or Temporary Signature of Certified Well Contractor Dale
By signing this form,1 hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or WNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page`to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (IQ 24a. For All Wells: Submit thisi form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
I
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 14 Method of test: Air 24c.For Water Supply&Iniection;Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 12oZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
li
f1