GW1-2022-08437_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES'
FROM TO DESCRIPTION
Well Contractor Name
3002-A 132 1" 150 f`'
162 rL 192 f`'
NC Well Contractor Certification Number 15.OUTER CASING;(for multi-cased wells)OR LINER(if a"livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 et' 112 f`' 6 1/4'. SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 21-428 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. fL in.
- !Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) iS:GROUT"
Irri ation FROM. TO • MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well- X,O:.. ft' 20+ f`' Bentonite Pour 47)501b Bags
Monitoring DRecovery ft. ft.
Injection Well:
i ft. ft.
Aquifer Recharge EIGroundwater Remediation
19i SANDlGRAVELPACK(if a livable)
Aquifer Storage and Recovery OSalinity Banter j FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer "20.DRILLING.LOG attach additional sheets if necessary)
El
Geothermal(Heating/Cooling Return) Other(explain under#21''Remarks) FROM To DESCRIPTION(color,hardness saiUrock type,grain size etc.)
0 ft" 28 f`' Red Clay/Dirt
4.Date Well(s)Completed:3-24-2022 Well ID# 28 et. 43 f` Brown Clay
5a.Well Location: 43 100 f`' Brown Sandcla
Johnny&Susan Beaver 100 fL 200 ft' Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft. 7
3917 Pageland Hwy. Monroe 28112. fL fL
Physical Address,City,and Zip
ft. ft.
Union 04-033-008F 21.REMARKS ,mot: n aiv
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.553 N 80.28.215 W _
4-7-2022
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this fonn, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or E?No 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 font.
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-I 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: 64 (ft.
Division of Water Resources,Information Processing Unit,
If water level is above casing,itse•'+" 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) 6 Method of test: Air 24c.For Water Sunaly&Iniectiorl Wells: In addition to sending the forni 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.
Fomt GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016