GW1-2021-02455_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver
FROM TO DESCRIPTION
Well Contractor Name
185 ft. ft
3002A ft. ft.
NC Well Contractor Certification Number 11'S'OIJTF,R CA51NG'forihultl+eds!dwells'OR->71NER`ir'a""Hcable
Carolina Well Drilling FROM I TO DIAMETER I THICKNESS MATERIAL
0 ft' 180 ft- 61/8 i" SDR21 PVC
Company Name 1iS'r` NER-CASING OR TUBING''edthbrtiiel cloked tat
2.Well Construction Permit#: 353507 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) fL h. in.
3.Well Use(check well use): ft. It. In.
Water Supply Well: : ',=:
FROM TO DIAMETER SLOT SIZE THICKNESSYMATERIAL
Agricultural [3Municipal/Public n. I in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fa fL In,
Industrial/Commercial [311esidential Water Supply(shared)
Ini ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f 20+ f" Bentonite Pour 43 501b Bags
Monitoring Recovery ft. n.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
°=19 ANU/GRAyEG.PA(11C ifa livable - r `� -., .rr.:.
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD ,
Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.`_BRt1,i 1NG LpG.'attach fiiltlltla'itidl-sheets It<ecessa _ a_ ;
Geothermal(Hearin Coolin Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/mck type,r in size etc.
0 f• 8 f` Brown Clay
4.Date Well(s)Completed: 6-17-2021 Well ID# 8 ft. 200 ft' Red Cla ock
ft. ft.
Sa.Well Location:
Mary Garceau ft. M
Facility/Owner Name Facility ID#(if applicable) r• r• 6'"
1095 Poplar Hill Church Rd. Polkton n. n.
Physical Address,City,and Zip ft. It. tt
bt
Anson 6445.00.02.8027 �`at REMARtCS
County Parcel Identification No.(PIN) 113fion Fir() saing WAR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
on
(if well field,one lat/long is sufficient) 22.Certification:
34.59.50 N 80.12.21 W 7-5-2021
6.Is(are)the well(s) Permanent or 13Temporary Si are of Certified Well Contractor Date
By signing this form, 1 hereby certify that the wrtll(s)was(were)constnucted in accordance
7.Is this a repair to an existing well: [3Yes or 53No with ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Conwrucrion Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature of due copy of this record has been provided to the well owner.
repair tinder#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 1 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 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depihv ifdi,(Jerent(example-3@200'au12@1001 construction to the following:
10.Static water level below top of casing: 32 00 Division of Water Resources,Information Processing Unit,
If water level is above caring,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniectfon 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 Mall Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 40 Method of test- Air 24c.For Water Supply&Iniectilon 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.
Fomr GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016