GW1-2022-07562_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver `14.WATER ZONES x"
Well Contractor Nune FROM TO DESCRIPTION
ft. fl.
3002-A 75
ft. ft. !
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)MIANFR(iF a arable)
Carolina Well Drilling FROM TO DIAMETER HCR NESs MATERIAL
Company Name
0 ft' 45 ft' 61/4 in' I SDR21 PVC
21-89 16.INNER CASING OR TUBING( eothermal dosed-loop)
2.Well Construction Permit# FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable ivell cunstiaction permits(i.e.UIC,Cuunry,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DTAMRTER SLOT SIZE TRICKNF.SS MAT F.RTA11,
Agricultural [3Municipal/Pubbc ft fL in.
1 Geothermal(Heating/Cooling Supply) WRecidential Water Supply(single) n R
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
_ 3 h-ri ation FROM TO MATERIAL EMI'LACEhfEMF METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ n Benton ite Pour(14)501b Bags
Monitoring 1311ecovery
injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK fifa licable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHO
Aquifer Test []Stormwater Drainage
ft ft.
Experimental Technology ®Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional,sheets if necessary)
FROM TO DFSCRTPTION(color,hardness soiltrock t rain size etc)
Geothermal(Heaton /Conlin Return) Other(explain under#21 Remarks
0 ft. 5 rt. Yellow Dirt
4.Date Well(s)Completed: 6-13-22 Well ID# 5 ft' 15 ft Brown Dirt
5a.Well Location: 15 et. 29 ft.
Brown Shale
Ricky Webster 29 rt' 1 550 ft. Blue Slate AUG P 2
Facility/Owner Name Facility ID#(if applicable) ft. n.
1602 Ellis Belk Rd.Monroe 28112 ft. rt. D°,lQiOG
Physical Address,City,and Zip
rt. rt.
Union 04-216-005 21.REMARKS
Camay Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/ininutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
34.82.180 N 80.56.624 W
6-22-22
6.IS(are)the well(s)OPermanent or OTemporary Signature of Certified V a ontractor 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 lallo with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out bump well contmectinn information and explain the nature of the copy of this record hav 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 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; 550 Ut-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
Fm-multiple ivells list all depths if different(example-3(a)200'mud 2@100� construction to the following:
ID.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 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,ruuuy,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) .5 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: 34o2 completion of well construction to t6 county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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