GW1-2022-04383_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3002-A 58,76 ft- 85,93 ft.
119 1[. 131 fL 147,155,181
NC Well Contractor Certification Number 15.:OE TER CASING(for multi-cased wells)ORLINER(if a livable)";c.
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 49 ft. 6 1/4" 'n' SDR21 PVC
21-186 ='16.INNER CASING OR TUBING(geothermal closed.loo
Z.Well COnSlrnetlOn Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.171C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): f[. ft. in.
Water Supply Well: 17.SCREEN "
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. fL
Industrial/Commercial Residential Water Supply(shared) t8.GROUT
lrri ation FROM TO MATERIAL" EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et' 20+ et' Bentonite Pour(19)501b Bags
Monitoring DRecovery ft. rt.
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL.PACK(if appilteablej '
Aquifer Storage and Recovery E3SaliniLy Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach;additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, ram size etc.)
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks)
0 fc. 10 fc. Orange Clay
4.Date Well(s)Completed:4-4-2022 Well ID# 10 f' 21 fc' Brown Sandcla
5a.Well Location: 21 fL 26 ft' Brown Gravel
Mark Lubenchenko 26 fL 200 ft, Granite
Facility/Owner Name Facility ID#(if applicable) fL ft.
10125 Bethel Church Rd.Midland 28107 fL fL
Physical Address,City,and Zip ft. ft.
Cabarrus 55357944820000 21.REMARKS
County Parcel Identification No.(PIN)
APR�2 6 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: MWW
35.16.616 N 80.33.006 W 4-7-202 lG�)I I
-7-2022 \
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E?No 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 fomi.
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 depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 22 (ft.) Division of Water Resources,Information Processing Unit,
1f 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 J
Division of Water Resources,Underground hrjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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.
Forst GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1