GW1-2022-08439_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 115 380
et. et.
ft. ft.
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 ft. 76 ft. 61/4" tn' SDR21 PVC
21-236 16.INNER CASING OR.TUBING(geothermal closed-loo-
2.Well CODStrnetlOR Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennitr(i.e.UIC,County,State,Variance,etc.) ft. f[ in.
3.Well Use(check well use):
r17.'SGREEN • ' 3 <<- -._ _
Water Supply Well: FROM TO DIAMETER SLOTSI'ZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) I GROUT
1ni ation FROM TO Y MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour 32 501bBags
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary
Geothermal(Heating/Cooling Return) rIOther(explain under#21 Remarks) E6f
TO DESCRIPTION(color,hardness,soillrock ty e, rain size,etc.)
56 ft' Red/Orange Clay
4.Date Well(s)Completed: 1-28-2022 Well ID# 63 ft. Brown Cla /Rock
5a.Well Location: 400 ft' Granite
Brothers Housing&Real Estate ea ft.
Facility/Owner Name Facility rD#(if applicable) ft. ft. A
5101 Stack Rd.Monroe 28112 Lot#1 ft. ft.
Physical Address,City,and Zip ft. ft.
Union 04-024-003 21::REMnRKs
✓r .I�..
County Parcel Identification No.(PIN) I '
Y J V V i\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.49.755 N 80.27.289 W
2-7-2022
6.Is(are)the well(s)mPermanent or OTemporary Signature of Certified Well ontractor Date
By signing this farm, I hereby certify that the tvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or RNo with 15A MCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,,fdl 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 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 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: 400 (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@I00) construction to the following:
10.Static water level below top of casing: 19 (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 Iniection 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 Itjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 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: 24oZ completion of well construction to the county health department of the county
where constructed.
Forni GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016