GW1-2022-06522_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
16
Frankie L.Oliver 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
86 ft. 95 ft.
3002-A
99 ft. 133 eL
NC Well Contractor Certification Number 1S OOUTER'CASING(for multi-cbsed;wells)OR LINER(if al) licable)
Carolina Well Drilling FROM I TO I DIAMETER 1 THICKNESS MATERIAL
0 ft. 82 ft' 61/4" in' I SDR21 PVC
Company Name
'16:INNER CASING OR<TUBING""( eothermal,closed-too
2.Well Construction Permit#' 21-278 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. f[. in.
3.Well Use(check well use):
I 17.`SCREEN
Water Su ..
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public et. ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) fa ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18;GROUT "
-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f' 20+ ft' Bentonite Pour(54)501b Bags
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge E]Groundwater Remediation
39:5AND/GRAVEL PAC K'(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DR1LLING.LOG(attach:additional:ahheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size etc.)
0 ft. 15 ft. Yellow/Brown Clay
4.Date Well(s)Completed:3-30-2022 Well ID# 15 ft- 42 ft' Brown Sand/Rock
5a.Well Location: 42 ft. 73 ft' Brown Rock
Kong Vang 73 ft. 200 ft. Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6623 Palafox Ln.Concord 28025 et. ft. --
Physical Address,City,and Zip ft. ft. APR 2 2
Cabarrus 55474723610000 If.iREMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tax t M'd
(if well field,one lat/iong is sufficient) 22.Certification:
35.32.608 N 80.52.819 `l,
4-7-2022
6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)coustnicted in accordance
7.Is this a repair to an existing well: r1Yes or 53No 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-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: 35 (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 Injection 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016