GW1-2022-10584_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
i
Frankie L.Oliver4t1r"
FROM TO' DFSCRII7iON
Well Contractor Name ft. ft.
167
3002-A
n n.
NC Well Contractor Certification Number
:i15.>01) R(A ,U'" Ai„ bill!'`e$`virells Qir 111V>Y P,.a 1)5ti1' .
Carolina Well Drilling FROM TO` t DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 44 ' n' 6 1/4 i"' SDR21 PVC
22-354 aJAA.:. .. r`0 Rl,
2.Well Construction Permit#: FROM TO f DIAMETER THICKNESS I MATERIAL
List all applicable well constuuction pesmits(le,UIC,County,State,Variance,etc.) n. ft, in,
3.Well Use(check well use): ft. n. in.
Water Supply Well "M i4S-0RE6N
FROM TO i I DIAMETER SLOTSiZE I TBICKNRSS I MATFRIAT,
Agricultural ®Mimicipal/Public ft. m in.
Geothermal(Heating/Cooling Supply) SaResidential Water Supply(single) tt s In.
Industrial/Commercial ®Residential Water Supply(shared)
Irrigation FROM TO 1 MATERIAL EMI LACFd111r1ST METHOD&AMOUNT
Non-Water Supply Weil: 0 ft' 26`+ n• Bentonite Pour(14)501b Bags
Monitoring Recovery a. n.
Injection Well:
Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery 13Salinity Barrier FROM Ttm' 1 MATERIAL I EMPLACEMENT MEMoD
Aquifer Test [3Stonnwater Drainage
Experimental Technology 13Subsidence Control n. ft.
Geothermal(Closed Loop) ®Tracer 2Dt R[tIi1TNG` "liititiSl7i2[;di'dtstfeitb"ifoiico "i 3 .r : '. v =;1
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM I TO nFSCRTMON color,hardness sontroek type,grain she etc)
0 tt 10 tt Brown Clay
4.Date Well(s)Completed: 10-12-22 Well ID# 10 ft 700 n• Blue Slate
Sa.Well Location: ft. n. R. `" r'
_ i—:
ft. n.
Ricky Phifer
LL
Facility/Owner Name Facility ID#(if applicable) ft. tt.
NOV 2
1310 East Sandy Ridge Rd.Monroe 28112 ft. n.
Physical Address,City,and Zap ft. ft.
Union 04-117-001G
County Parml identification No.(PIN)
5b.Latitude and longitude In degreeshninutes/seconds or decimal degrees:
(if well fold,one lai/long is sufficient) 22.Certification•
34.53.487 N 80.31.194 W
iL 11-10-22
6.Is(ore)the well(s)OPermanent or 13Temporary Sig tore of Certified Well Contractor Date
By signing this form.I hereby cenify Mai the well(s)was(were)constructed in accordance
7.Is this a repair to an eRlsting well: ®Yes or Jallo with 15A NCAC 02e.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,jell our krunrm trell construction information and explain the nature of the copy of this reenrd hat been provided to the well owner.
repair ender lJ21 remarks section or on the bock oJthis,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: 700 (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells 1W all depths if different(example-3(a)2Ot1'and 2@100� construction to the following:
10.Static water level below top of casing: 34 (ft.) Division of Water Resources,Information Processing Unit,
tf water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For iniectlon Wells: In addition to sending the form to the address in 24a
Air Rotary above,also subinit 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: i436 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) •5 Method of test: Air 24c.For Water Supply&Infection Wells: In addition to sanding the form to
the address(es);above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount. 42o2 completion of well construction to;the county health department of the county
where constructed. !{
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016