GW1-2022-09570_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) ForInteanal Us Only:
1.Well Contractor Tnfonnation:
I t
Frankie L.Oliver ifj44VAT
Wen Contractor Natne FROM TO DESCRH'TION
424 [` 436 n• I
3002-A 456 [`' 469 n' 570 1
NC Well Contractor Certification Number 13 OTIINRY2oAb tir�i ulft °sd8; "etlg tilt t11NF11"' liVile. `"
Carolina Well Drilling FROM To DIAMETER TMCKNESS MATERIAL
0. �4R �Dl/4 1n' SDR21 PVC
n. n
Company Name 22-333 � i�losedll ��<a.�_�s a xs '._,:.=.�`i'-•
2.Well Construction Permit#l: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consbxction permits(i.e.UIC,County,State,Variance,etc.) [t. ft. In.
3.Well Use(check well use): [t. n. in.
INo
ter Supply Well:
FROM TO n1AMGTFR SLOT Sl7F TTITCKNFSS MATF.RTAL
gricultural ®Municipalt'Public R % In.
eothermal(Heating/Cooling Supply) ®Residential Water Supply(single) tt i4 in.
ndusuial/Cottvnercial ®Residential Water Supply(shared) ,411
y
Irrigation FROM TO MATERIAL El1II'LACEMMIr METHOD&AMOUNT
n-Water Supply Well: 0 f`' 20+ n Bentonite Pour 14 501b Bags
Monitoring Recovery, ft. n.
ection Well:quifer Recharge ®Groundwater Remediation
AV T A tt i 1 liitii61l = ws' -'quifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLALEME.tTMETHOD
quifer Test Stnrmwater Drainageft. n.
xperimental Technology ,Subsidence Control ft. n.
Geothermal(Closed Loop) 13Tracer :211DIti[:UT1tG G`:(iti;scli'gdiliilufii6L liellfh`Itces7a s�.5',d'- t� "' .:
Geothermal eatin Coolie Return) Other(explain under 421 Remarks FROM To nFSenmTON color hardnett twtthock t rain sbe etc
0 n. 2, ft' Brown Clay/Shale
4.Date Well(s)Completed: 9-15-22 Well ID#1 23 f`' 6 0 n' rani
So.Well Location:
Circle S Ranch et. n. t o.
Facility/Owner Name Facility M#(if applicable) ft. j ft.
0612
White Store Rd. Monroe NC 26112 Well#1 [t. ft.
UKK
Physical Address,City,and Zip ft. i ft. m01 hf TC
Union 09-066-001 n"2472P
County Parcel Identifimtiun No.(PIN)
Sig.Latitude and longitude in degreeslrulnutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Cert(fieatior}:
34.56.603 N 80.27.861 W h
9-26-22
6.Is(are)the well(s)JOPermanent or E]Temporary Si of CmTW
i ed Well Contractor Date
13y signing this form,I hereby certify that the well(s)wKa(were)constructed in accordance
7.Is this a repair to an existing well: ®Yea or SINo with 15A NCAC 04C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
JJthis is a repair,fill nutkssoim ivell couuructinn infornmtinn and explain the nature of the copy nJ/his r ernrd has been provided to7he well owner.
repair under#21 remark section or on the bark of thi form. 23.Site dlagral1��lr 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 ur well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction detils. You may also attach additional pages if necessary.
drilled: SUBMITTAL ((INSTRUCTIONS
i
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lict all depths ifdi,(ferent(exrtmple.3@200'a id 2@100� construction to e following:
10.Static water level below trip of casing: 26 (fL) Division of Water Resources,Information Processing Unit,
If waler level is above casing,rise"+" 1 17 Mail Service Center,Ralelgb,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For ec on Wells: In addition to sending the form to the address in 24a
Air Rotary above,also su mit one copy of this form within 30 days of completion of well
12.Well construction method: construction to a following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1I,636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 24 Method of test: Air 24ca For Water Sual ly&IniectIIon Wells: In addition to sending the form to
the addresses above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 36oZ completion of ell construction to the county health department of the county
where constru ed.
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Form GW-I North Carol inn Department of Environmemal Quality-Divisgon of Water Resources. Revised 2-22-2016