GW1-2022-07567_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD (GW-1) For Intemat URB Only:
1.Well Contractor Information:
Frankie L.Oliver 14
FROM TO, DESCRIPTION
Well Contractor Name
3002-A 190 ft 19fi' rt.
217 rt' 235 ft. 247315418
NC Well Contractor Certification Numbers .
3 9$� tt«hv � p:S ."Ot .di• "1;ifPi+�$� i 'dl?Is`t1N�Tt�iP'� ci�l�
Carolina Well Drilling ",�01
DIAMETER ' IMCKNESS MATERIAL
Company Name
' n' 6 14 D' SDR21 PVC
2.Well Construction Permit#: 22-213 FROM I TO` DIAMETER THICKNESS MATERIAL
List all applicable well conshtection pennils(i.e.UiC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): (t. ft. 9n.
xfx7hi(1it_ )" ''` ,-z: n �t•g a .,), �.>t ix°+t°ra
Water Supply Well: FROM I TO I niAMfTER SLOTSi7F ITHICKNESS MATR.RiAL
Agricultural ®Municipal/Public ft. iL In.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) It
g- in.
Industrial/Comtnencial ®Residential Water Supply(shared) A[�R(y r 7.77777,�,7, 35 ,
Irrigation FkOM TO I MATERIAL EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: 0 ft 2 C+ r` Bentonite Pour 23 501b Bags
Monitoring 13Recovery ft. ft.
Injection Well:
Aquifer Recharge ®Groundwater Remediation
�19i�wtltcr/GtiA �GK`r• t �1�1.:1�`»=�k�°< ��' ":'=ice '���<r ��.
Aquifer Storage and Recovery Salinity Barrier FROM TO, MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stonnwater Drainage rt• h'
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 'O'i(IiltTltL�IN Da fitt3id8 NiifiillPRlf` If1t llr '<H „s,<.,. t
Geothermal eatin Coolin Return) Other(explain under*21 Remarks FROM I TO nFSCRiPTIOx color,hard sotl/roek tym grain sire etc
0 4 ft• Red Clay
4.Date Well(s)Completed: 7-18-22 Weil Hm Well#2 48 rl• 165 n• Brown Sh le
Sa.Well Location: 165 ft. 5 0 n'
Granite
Circle S Ranch n. ft. ' =
Facility/Owner Name Facility IDk(il'applicable) ft. n.
Austin Rd. Monroe 28112 ft. n. AlJG 1 ► 2022
Physical Address,City,and Zip ft. fl
Union 04-213-010 rf
;e L
County Parcel Identification No.(PIN)
F
5b.Latitude and longitude In degreeshninutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification
34.50.170 N 80.33.398 W
7-27-22
6.Is(are)the wells)jaPernranent or Temporary
Signature of Certifiedell Contractor Date
Br signing this form,1 herebp certify that the well(s)was(were)catuuttcted in accordance
7.Is this a repair to an existing well• ®Yes or Jallo with 15A NCAC 02�.0100 or 15A NCAC 02C.0200 Well Consmection Standards and that a
if this is a repair,fill out know well consrmairm information aril explain the nature of the copy of this record l m been provided to the well owner.
repair tinder#11 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]ESTRUCTION5
9.Total well depth below land surface: 500 Ut-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdii ferent(euanple-3@200'and 2@1001 construction to ttie following:
10.Static water level helnw top of casino,: 56 (ft•) Division of Water Resources,Information Processing Unit,
If water level is above caring,rise"+" I6 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (tn.) 24b.For Injecil in ells: 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 toto following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 16P6 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: Air 24c.For Water I Supply&I •ection Wells: In addition to sending the form to
the address(esY" ibove, also subtnit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount 30oZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Divisiodh of Water Resources Revised 2-22-2016
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