GW1-2022-08443_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
91 ea 277 ft.
3002-A et. et.
300
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased wells)OR LINER(if a 6cable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 fL 45 fl' 1 61/4" In' I SDR21 PVC
Company Name
16.INNER CASING TUBING(geothermal closed-loop)
2.Well Construction Permit#: 22-27 EFROM
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,Cotany,State,Variance,etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: EN�
PP y TO DIAMETER SLOT SIZE THICKNESS MATERIAL
- Agricultural EIMunicipal/Public fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) T"Irrigation
. Irri ation TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(12)501b Bags
Monitoring ORecovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge [IGroundwater Remediation
19.SAND/GRAVEL PACK(if a livable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control et. ft.
`Geothermal(Closed Loop) Tracer �20.'DRILLING LOG(attach additional sheets if necessar')
FROM To
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) DE (color,hardness,soiUrock ty a rain size etc.)
0 tti• 9 ft* Reedd C Cl70N lay
4.Date Well(s)Completed:4-4-2022 Well ID# 9 ft' 325 rL Blue Slate
5a.Well Location:
Lewis E.Woolley fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5317 Stack Rd.Monroe 28112 fL fL
Physical Address,City,and Zip ft. ft. c9 OpSlt+1�� .
Union 03-186-014 21.REn1ARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
34.49.286 N 80.26.524 W
4-7-2022
6.Is(are)the well(s)OPermanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E?No with ISA NCAC 02C.0100 or 1SA 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 oumer•.
repair under#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
S.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: 325 —(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: 40 (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 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(,-pm) 3 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: 220Z completion of well construction to the county health department of the county
where constructed.
Fortin GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016