GW1-2022-08432_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Frankie L.Oliver ;.14:�WATERzoNEss
FROM TO DESCRIPTION
Well Contractor Name 290 ft' 316 ft.
3002-A 396 ft. 487 ft.
NC Well Contractor Certification Number 151`OUTER CASINg.'(formulti=cased*elis);OR LINER'ff ahcable ,
FROM TO DIAMETER THICKNESS MATERLAL
Carolina Well Drilling
p ft. 117 fL 61/4 i"' SDR21 PVC
Company Name IC INNER CASING,OR TUBING(eothermal'closed loo
22-010 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, in.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): „k
rr
i47.FSCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE, THICKNESS MATERIAL
Agricultural [3MunicipWPublic ft. It. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) [L ft in.
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
[rri a[ion
FROM TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT
Non-Water Supply Well: 0 It- 20+ ft. Bentonite Pour 21)501b Bags
Monitoring Recovery ft. ft.
Injection Well: ft. it.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEI PACK'if"a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIA=soiVmck
NT METHOD
Stormwater Drainage ft. ft.
Aquifer Test � g
- Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
20:'DRILLING LOG.(attach addition
FROM TO DESCRIPTIONpe, m size,etc.)
RGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 100 ft* Brown Clay/Rock
4.Date Well(s)Completed:3-28-2022 Well ID# 100 ft 525 ft' Granite
ft. fL
5a.Well Location:
Tommy McAlister rt. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
4911 Leonard Morgan Rd.Marshville 28103 ft. ft. r—
Physical Address.City,and Zip ft. ft 6 20 7
Union 03-021-006 ,, REN ARKS °
County Parcel Identification No.(PIN) JOG _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.52.562 N 80.19.617 W 4-12-2022
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this fonn,I hereby certify that the well(s)was(were)constnicted in accordance
7.Is this a repair to an existing well• nYes or Wo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200]Veil Construction Standards and that a
lfthis is a repair,fill out known well construction it fonnation and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this fort. 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: 525 (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: 24 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 Infection 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) 13 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: 32oZ 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