GW1-2022-03703_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For Internal U e Only:
1.Well Contractor Information:
Frankie L.Oliver a4wATER4zt)N
FROM TO' DESCRIPTION
Well Contractor Name
105 rt. 109 FG
3002-A
121 rt' 149 ft 183
NC Well Contractor Certification Number ,:15 OUTCR CAS G.[or.mul 1 caikd.@ells'UR L1NI R;!te'` livable
Carolina Well Drilling FROM TO, DIAMETER THICKNESS MATERIAL
0 n' 79 'L 16 1/4" 1" SDR21 PVC
Company Name
-i6`II9NER CAS1ltlG,l)R TUBIIVG ''"thcrtiiel dosed•!oo' -
2.Well Construction Permit#: 21-310 FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well ronsinection permits(i.e.UIC.County,State,Variance,etc.) ft. rL In.
3.Well Use(check well use): R. lG In
Water Supply Well: 17iiSGREEN
PPY FROM I TO I DIAMETER I SLOT SIZE THICKNESS MATERIAI.
Agricultural 13Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) BaResidentiall Water Supply(single) rL ft. In.
lndustrial/Commercial Residential Water Supply(shared) 18.GR0 T s, f
Irri ation FROM TO: MATERIAL EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: 0 n' 20 Bentonite Pour 32 501b Bags
Monitoring Recovery ft. ft
Injection Well:
ft. iG
Aquifer Recharge Groundwater Remediation
39.,SAND/GRAY "P.A'CK ito llcfiblb -,
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage B- n
Experimental Technology 13Subsidence Control n. ft.
Geothermal(Closed Loop) Tracer 8 20 DRILLING ti e`ttech addldoriel;atieets if lcecessar ;
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solllwk(yM grain sire etc.
0 n' 30� rL Red Clay/Dirt
4.Date Well(s)Completed: 3-14-2022 Well ID# 30 n' 71 fL Brown Sand/Rock
5a.Well Location: 71 ft. 200f
L Granite
Donald Kevin Stone ft. rL
Facility/Owner Name Facility ID#(if applicable) tt' n'
365 Pinewood Ln. Midland 28107 n• ra
Physical Address.City,and Zip fL R'
Cabarrus 55248386500000 E1REMARKS:�C' ``, -
County Parcel Identification No.(PIN) .AR
2029
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.13.977 N 80.34.686 W I lr
3-23-2022
6.Is(are)the well(s)gPermanent or Temporary Signature of Certified Well Contractor Date
Ry signing this form,Il hereby certify that the[sills)taus(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or RNo with 15A NCAC 02C�0100 or 15A NCAC 02C.0200[Nell Construction Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of the copy of this record hal been provided to the well owner.
repair tinder#21 remarks section or on llte back of this jonn.
23.Site diagram of 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-I is needed. Indicate TOTAL NUMBER of wells construction details; You may also attach additional pages if necessary.
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 00 24a. For All WeIL Submit this form within 30 days of completion of well
For nniltiple wells list all depths ifdii ferent(example-3(a3200'and 2@1001 construction to the following:
10.Static water level below top of casing: 65 (ft.) Division`f 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 ollowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Wafffi r Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16361Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 15 Method of test AIr 24c.For Water S oDly &Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 120Z completion of well1 construction to the county health department of the county
where constructed.
Fomt OW-1 Nonh Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016
i