GW1-2022-05602_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
i
Frankie L.Oliver 14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
168 n. 192 ft.
3002-A
214 n. n'
NC Well Contractor Certification Number 15.OUTER CASING for molt'-cased wells OR LINER if a liable
Carolina Well Drilling FROM TO DIAMETER TffiCKNESS MATERIAL
Company Name 0 fA 125 ft' 61/4 In. I SDR21 PVC
N/A 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) rt. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public fa ft. In.,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n, ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It' 20+ n. Bentonite Pour 24 501b Bags
Monitoring ORecovery ft. ft.
Injection Well: ft et.
i Aquifer Recharge Groundwater Remediation 19,SAND/GRAVEL PACE(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage n' n•
Experimental Technology Subsidence Control z-fL ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock type,pain eta
0 n. 35 fL Brown/Oran a Sand
4.Date Well(s)Completed:5-10-22 Well ID# 35 n' 46 "' White Clay
Sa.Well Location: 46 n. 70 n' BrownClay
Ronnie Morgan 70 fL 78 ft. Pink/Red Clay
Facility/Owner Name Facility 1D#(if applicable) 78 n. 86 ft' Brown/Yellow Sand
Gatewood Rorie Rd. Morven 28119 86 ft. 100 n. Gray Clay
Physical Address,City,and Zip 100 n' 250 ft• Blue'Slate/Granite -- 0 C f-
Anson N/A 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "on Pr2?CtTesrin Unil
(if well field,one lat/long is sufficient) 22.Certification: D%VQ/BOG
34.50.288 N 80.20.444 W
5-16-22
6.Is(are)the well(s)&aPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ONo 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 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-I 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: 250 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-.3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 63 (ft.) Division of 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 following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,l Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Air 24c.For Water SuuDly &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: 16oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016