GW1-2022-05599_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES.
FROM TO 1 ESCRIIITION
Well Contractor Name
269 tt. ft.
3002-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(For multi-cased wells)OR I.INF a iicable)
Carolina Well Drilling FROM I To 51AMETER THICKNESS MATERL41,
Company Name 0 ft. 142 "' 6 1/4 in' I SDR21 PVC
21-371 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit ft; FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consnxction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM To DIAMETER, SLOT SIZE THICKNESS MATERTA1,
Agricultural Municipal/Public M t't. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. R,
Industrial/Commnercial Residential Water Supply(shared) 1R.GROUT
Irri ation FROM TO MATERIAL EMI-L.ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ [t. Bentonite Pour(30)501b Bags
Monitoring ORecovery
Injection Well:
f[. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAW..T:PACK(ifapplicable)
Aquifer Storage and Recovery []Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage
ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO T)FSCRTPTION(color,hardness soil/rock rain size etc)
rm Geotheal(Heating/CoolingReturn) Other(explain under#21 Remarks
0 ft. 22 ft, Red Clay
4.Date Well(s)Completed: 4-12-22 Well ID# 22 ft' 300 ft. Granite
ft. ft. �.�.. ;
5a.Well Location:
Lee&Elizabeth Foster ft. Ft'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
310 Pinewood Ln.Midland 28107 ft. ft. n vr- on n
Physical Address,City,and Zip
Ft. Ft.
Cabarrus 55249375370000 21.REMARKs
County Paicri IJcatification No.(PIN)
5b.Latitude and longitude In degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-.
35.13.541 N 80.34.323
C:: ��� 54-22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
Br signing this./orm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or [?No with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known svell construction information and explain the nature of the copy of this record has been prnvided to the well niter.
repair under#21 remarks section or on the back of this farm.
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: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(diflerent(example-3(q�200'and 2(a3100D construction to the following:
10.Static water level below top of casing: 30 (fh) Division of Water Resources,Lmformation Processing Unit,
if water level is above casing,use"+" 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 subunit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direccth 12.Well construction method: construction to the following:
t push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) 45 Method of test: Air 24c.For Water Supply&Injection 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: 18oz 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