GW1-2022-07563_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver %14.WATER ZONES.
FROM TO DESCRII'TION
Well Contractor Naine
116 of 385 ft. f
3002-A ft. ft.
NC Well Contractor Certification Number t5:OLiTF.R CASING(for inulti-cased(wells)OR i.INF.R(if-a livable
Carolina Well Drilling FROM TO DIAMETER THICKNESS I MATERIAL
0 ft' 45 It' 61/4 " SDR21 PVC
Company Name A16.INNER CASING OR'TUBING,( eothi rinal closed•loo )s;'
2,Well Construction Permit#- 22-169 FROM TO DIAMETER THICKNESS MATERIAL y
List all applicable well cant action permits(i.e.UIC,Caun y,State,Variance,etc.) ft. ft. rn•
3.Well Use(check well use): ft. ft. in.
17.SCREEN
i"Inigation
ater Supply Well: .
pp y FROM TO DIAMETER11 SLOT S17% MCKNF.SS MATF.RTAL
Agricultural [3Municipal/Public ft IL in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL in.
Industrial/Cormnercial Residential Water Supply(shared) 1lirGROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20+ n' Bentonite Pour(19)501b Bags
Monitoring Recovery
injection Well:
:3 Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery []Salinity Barrier FROMND/GRTtVFi,PACK�DLATERIALe EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.-DRILLING LOG(a'ttacl ad'ditlefial sheets if netessa )a
FROM TO DFSCRTPTiON(color,hardness soiVrock rain size etc)
_ Geothermal(Hearin /Conlin Return) Other(explain under#121 Remarks)
0 ft. 18 ft, Brown Shale/Clay
4.Date Well(s)Completed: 7-20-22 Well ID#1 18 It- 700 ft. Granite
5a.Well Location: ft. ft. s s tf'""
Paul Lucas ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. AUG J
3124 Ridge Rd. Indian Trail 28079 ff tt' c.� Przx, ip Unil
Physical Address,City,and Zip ft. ft. D'9RIQr OG
Union 08-264-008 zr.R�MARxs:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lac/long is sufficient) 22.Certification:
35.60.001 N 80.34.238 W
8-5-22
6.Is(are)the well(s)JOPermanent or Temporary Signature of Cenihed Well Contractor Date
By signing This form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an elosting well: [3Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out kn it7r well construction information and explain the nature of fhe 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 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: 700 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welis list all depths ifdifferent(extimple-3L200'and 2glt10� construction to the following:
10.Static water level below top of casing: 21 (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 mt pu construction to the following:
(i.e.auger,rotary,cable,direct pushh,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&Iniection Wells: In addition to sending the form to
the addrrss(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount- 42oZ completion of well construction to the county health department of the county
where constructed.
Foun GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016