GW1-2022-09571_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
FrankieL.Oliver k�w.rj �Mw,
Weft Cuntmutur Name FROM TO n. DESCHRMON
ec.
3002-A 128 223
315 et' 437 n' 466,492
NC Well Contractor Certification Number +Ib.:aLi11gKRC/t 1NG rnfulif�e$; el�s`OiltctlYffif"If`te" lehtil'e ` '
Carolina Well Drilling FROM TO I DIAMETER TFHCKNV;S MATERIAL.
Company Name 0 n' 43 n' 61/4� i°' SDR21grtllii PVC
6D: +"Gi4.4Ii�t nvr.�..�atlie �tel e'
2.Well Construction Permit#: 22-334 FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well cunstntcaon permits(i.e.I11C,County,State,Variance,etc.) n. ft. iu.
3.Well Use(check well use):
J )17�SGk1�itT�7,`Q` t'� 5 kF'"yp;<.
A
erSupplq Well: FROM TO DIAMFTKR Sr.OTS17F, THICKNESS MATERIA►
ricultural ®MurticipaUPublic ft. ft. in.
othermal(Heating/Cooling Supply) 13Residential Water Supply(single)dusttial/Cornmercial QRcsidential Water Supply(shared)n ation FROM TO MATEICIAL F�tfPLACEMENT METHOD&AMOUNT-Water Supply Well: 0ft' 20+ n. Bentonite Pour 16 501b Ba s
onitoring Recovery n, ft.
ction Well:quifer Recharge ®Groundwater Remediadon
F
R'1; t�P0X 11 `lteebquifer Storage and Recovery 13Sahnity Barrier Tt► MATERIAL EMPLACEMENT METHOD
quifer Test ®Stonmwater Drainage n.
xperimemal Technology Subsidence Controleothermal(Closed Loop) Tracereothermal(Heating/CoolingReturn) Other(explain under#21 Remarks To! nFSCRH'T1ox color,hardness solVrock cam sire etc.
22 ft' Brown Cla /Shale
4.Date Well(s)Completed: 9-19-22 Well ID# 6 0 n' Granit5a.Well Location: n. �..4
Circle S Ranch rc. ft.
Facility/Owner Name Facility ID#(if applicable)
White Store Rd.Monroe NC 28112 Well#2 rt. n.
Physical Address,City,and Zip ft. n 1 OfiYt �.
.
Union 09-066-001 lzlxr
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degreeshnlnutes/seconds or decimal degrees:
(if well field,one lam/long is sufficient) 22.Certification:
34.56.603 N 80.27.861 W
� 9-26-22
6.Is(are)the well(s) Permanent or Temporary Si tore of Certified Well Contractor Date
By signing this John.I hereby certify that the well(s)trnt(were)consintcied in accordance
7.Is this a repair to an existing well: [3Yes or WNo with 15A NCAC 0 C.0100 or 15A NCA'C 02C.0200 Well Constntcilon Standards and that a
IJthis is a repair,fill out hummn well conttraclion it fonnatint arm]explain the nature t f thr cap)'oJthis recur f hfls been provided tn',the well oKTer.
repair under lf21 rcrnarb section err an 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 I 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: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple tveliv 1W all depAt if d(jjerew(ex<onple-3V00'unit 2@100� construction to�he following:
10.Static water level below top of casing: 27 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above rasing,use"+" I617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Ito ec on Wells: in addition to sending the form to the address in 24a
Air Rotary above, also su rnit one copy of this form within 30 days of completion of well
12.Well construction method: construction to Pe following:
(i.e.auger,rutary,cable,direct push,etc.)
Division of!Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Air 24c.For Wa r Su 1 & 'action Wells: In additiun to sending the form to
the ses addres above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 36o2 completion of well construction to the county health department of the county
where constru tad.
Folm GW-I North Carolina Department of Environmental Quality-Divi ion of Water Resources Revised 2-22-2016
I ,