GW1-2022-09208_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal U e Only:
1.Well Contractor Information:
Frankie L.Oliver ..... ..... 5,RyftL
Well Contractor Native FROM TO DESCRUITION
290 ?fL
3002-A ft. ft.
NC Well Contractor Certification Number
Carolina Well Drilling FROM TO DIAMETER I THICKNUM MATERULL
0 ft- 45 ft- 6 1/4!'n- SDR21 PVC
Custipany Nurric
A,"(01011M AINOM 01044100"12;,f2l
2.Well Construction Permit#: 22-009 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well consouction permits 0.e.UIC,Cusany,State,Variance,etc.) ft. fL In.
3.Well Use(check well use): ft. ft. in.
lu,
Water Supply Well: FROM I TO THAMFM SLOT S117F. I THICKNESS I MATF.AIAr
Agricultural 13M=icipalftblic ft. R. In.
Geothermal(Heating/Cooling Supply) SIResidential Water Supply(single) fL fL In.
Industrial/Commercial ®Residential Water Supply(shared) .30 R
Irrigation FROM TO I MATERIAL EMIILACEKWT METHOD As AMOUNT
Non-Water Supply Well: 0 ft' 20+ rt' Bentonite Pour(10)501b Bags
:)Monitoring E3Recovery ft. ft.
Injection Well: ft. I
:)Aquifer Recharge ®Groundwater Remediution
%
Aquifer Storage and Recovery [3Salinity Barrier FROM I TO I MATERIAL Empt.40EMENT METHOD
Aquifer Test [3stormwater Drainage ft. I rt.
Experimental Technology [3Subsidence Control ft. ri.
Geothermal(Closed Loop) ®'pacer _G,,,Voo AddliI&Qrsheetili.We�Aij)l
1 41 .4
FROM TO I nfSCRTPTTON(color,hardness,solUrsitit qM grain slit,etc
Geothermal(Heating/Cooling Return) M other(explain under#21 Remarks) I
o 1,4 Red Clay
4.Date Well(s)Completed: 9-2-22 Well ID# 14 725 Blue Slate
ft. ft.
5a.Well Location:
ft. ft.
Vitali BeIii
Facility/Owner Name Facility 1D8(if applicable) ft. ft. SVP kJ
@
Hemby Woods Lot#16 Moser Circle Indian Trail 28079 ft. ft.
Physical Address,City,and Zip ft. rtMr
unil
Union 07-042-024
Cuunty Panel Identification Nu.(PIN)
5b.Latitude and longitude In degrees/ndnutes/sexonds or decimal degrees:
(if well field,one iattiong;is sufficient) 22,Certification,-
35.50.356 N 80.37.421 W 9-19-22
6.Is(arc)the well(s)OPermanent or [3Temporary Signature of Ccrdfi� 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: ®Yes or NNo with i5AVCAC 02t.0100 or UA NCAC 02C.0200 Well Construt-tion Standards and that a
If this is a repair,fill nut blown is-ell c-anuchnn informalinn and eaplairy the nature of the copy of this record hat been pmvided in the well owner.
repair under#21 rentarb section or on the back of this form. 23.Site diagram'or additional well details:
You may use the,back of this page to provide additional well site details or well
8.For GcoprobefDPT or Closed-Loop Geothermal Wells having the sarne I
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: tSTRUCTION
9.Total-wtffi depth below i"d surface: .725
_tn-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivelk lie all d--prALf if*fferent(example-3Ca)d00'and 2@1001 construction to the following:
10.Static water level below top of casing: 25 (ft.) Divisi Resources,Information Processing Unit,
If water level is above casing,use 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
above, also subrMt one copy of this form within 30 days of completion of well
12.Well construction method: All,Rotary construction to die following:
(i.e.auger,rotary,cubic,direct push,etc.) I
Division of Water Resources,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS.ONLY: 1166 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm)_ .5 Method of test- Air 24c.For Water iSupply&Injec,tion Wells: In addition to sending the form to
the address(es) bove, also submit one copy of this farm within 30 days of
13b.Disinfection type- 70%HTH Amount: 44oz completion of Jell construction to the county health department of the county
where constmucte d.
Form GW-I North Carolina Department of Environmental Quality-Divistio i of Water Reqourc& Revised 2-22-2016