GW1-2022-09206_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver ? d \V,A3Filf, I!1E5 a xie:, .e't !r.fs t: s z'H` *km
Well Contractor Name FROM TO DFSCRII'TION
52.64 et' 159'
3002-A u.
257
l001R
NC Well Contractor Certification Number w -
5 t3U$RiEH A1511!1GIff- pR fa7N 1t:'irs t3b1
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATM41.
Company Name
0 ft. 44 ! ft. 6 1!4 An. SDR21 PVC
16NlyEtt , i e; a (EltisEd)oe :,
2.Well Construction Permit It: 22-95 FROM TO" i DIAMETER THICKNESS MATERIAL.
List all applicable well construction perrtrfts(i.e.UIC,County,State,Variance,etc.) [t. z ft.
3.Well Use(check well use): ft. I. in.
i
Water Supply Well:
FROM I TO OTAMFTF.R S1.OTSiSI 7,E THICKNESS I MATF.RTAi
Agricultural ®Municipal/Pablic ft R in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. n. in•
Industrial/Commercial ®Residential Water Supply(shared) A G'b. .
Irrigation FROM I TO I MATFRW, EM IL ACEAURNr METHOD&AMOUNT
Non-Water Supply Well: 0 tt' 20+ n' Bentonite Pour 14 501b Bags
Monitoring 13Recovery tt. ft.
injection Weil: ft. n.
Aquifer Recharge ®Groundwater Remediation �y t"D
Aquifer Storage and Recovery Salinity Barrier FRAM TO MI,TERLAL ItMP A(7MWT Aquifer Test [3Stormwater•Drainage ft ft.
Experimentai Technology Subsidence Control n. ft.
Geothermal
osed
op) [3Tracer
Gt otter (Cleatin ConlinRetum Other ex lain under#21 Remarks O tt T 1 nBrOWn Cle /ROCkm sottlroek lie, rrO site.
VROM etc.)
4.Date Wells)Completed: 9-7-22 Well ID#1 25 tt' 350 n' Blue Slate
ft, Ht.
5a.Well Location:
Amber Griffin rt. n. ' ; .
ft. ft.
Facility/Owner Name Facility ID#(it applicable)
2411 Snyder Store Rd.Monroe 28112 ft n SFP
rt. ft.
Physical Address,City,and Zip
°i21:RE1tifAR1GC" MITIc " * '
Union 03-168-003 ;0
County Patel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22,Certification,:
34.54.493 N 80.26.200 �(r �`-'y 9-19-22
6.Is(are)the well(s)apermanent or 13Temporary
Signa/�ttve of Cetti>i ed Well Contractor Date
11y signing this form,1 hereby certify that the well(s)war(Ivere)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Sallo ndth 15A NCAC 02C.0100 ur 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill nut burl,7r Iven eonunection ittformatinn and explain the nature of the copy of this rernrd,has been provided to Me well nVVner.
repair tinder#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 puge to provide additional well site details or well
construction details. You may also;attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTJONS'
9.Total well depth belowland surface. 350 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple ivel1v fist all depths if different(er noe-3kg200'am12@1001 construction to the following:
10.Static water level below top of casing: 25 (ft,) Division of Water Resources,Information Processing Urdt,
If tvaler level is above casing,use"+" 1617 Mail Service Center,Ralelglt,NC 2769 9-1 6 1 7
11.Borehole diameter: 6 (in•) 24b.For[We on 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: 1�36 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3•5 Method of test: AIr 24c.For Wate' Suunly&Injection Wells: In addition to sending the form to
the address(es)l above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount- 22oZ completion of well construction to the carroty health department of the county
where constructed. !4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Recourcea Revised 2-22-2016
I