GW1-2022-05580_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver la.WATER ZONES
FROM TO DESCRH'TION
Well Contractor Name
3002-A 235 It. 239 ft.
373 It' 385
NC WeII Contractor Certification Number 15.OUTER CASING(for multi-cased ivells)OR iANF.R(if ap livable)
Carolina Well Dulling FROM TO DIAMETER THICKNESS
Company Name 0 45 MATERLAI
IL It' 61/4 SDR21 PVC
22-136 16.INNER CASING OR TUBING( eotherinal closed-lao'
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable ivell conduction 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 DIAMRTFR SLOT STZE TATCKNF.SS MATF.RTAi.
Agricultural 3 Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
1ndustriaUCormnercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMI'LACEIi1ENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20+ rt. Bentonite Pour(14)501b Bags
_,Monitoring ORecovery ft. ft.
injection Well:
f[. f[.
:—)Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVET:PACK ar applicable)
Aquifer Storage and Recovery 13Sallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage
ft. ft.
Experimental Technology 0subsidence Control ft. ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary r
FROM TO DFSCRTPTTON(color,hardness soiltrock rain stze etc)
Geothermal(Iieatin /Coolie Return) Other(explain under#21 Remarks)
0 ft. 6 ft. Red Dirt
4.Date Well(s)Completed: 6-1-22 Well ID# 6 ec. 13 ft. Brown Dirt
5a.Well Location: 13 IL 400 It. Granite
David Griffin ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft.
4507 Morgan Mill Rd.Monroe 28110 ft. ft. Q 20
Physical Address,City,and Zip it. ft. I171foo'a'S$(011 P 1
Union 08-138-006D 21:`REMARKS nN
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:
35.05.579 N 80.49.287 W
D:ix 6-6-22
6.Is(are)the well(s)gPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify ihta the well(s)was(were)contrucled in accordance
7.Is this a repair to an exjsting well: [3Yes or RNo with 15A,rVCAC 02C.0100 or 15A IJCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill eta kwwn well cotistructinn information and explain the nature of the copy of this record has been provided in the well nwnei.
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: 400 (ft.) 24a. For All Wells: Submit this forth within 30 days of completion of well
Ft))-multiple wells list all depths if different(example-3(a)200'and 2(a)Inn') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casigq,itse..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this forte 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
13a.Yield(gpm) 3 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: 24OZ 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