GW1-2022-10588_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Frankie L.Oliver 14.WATER ZONES, .
FROM TO DESCRH'TION
Well Contractor Name
73 rt. 176 ft.
3002-A
323
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased wells)OR LINER(if a' licable
Carolina Well Drilling FROM I TO I DIAMETER I THICKNESS MATMUL
0 ft' 54 It- 61/4 tn' I SDR21 PVC
Company Name
22-382 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cunsn'uctiun permits(i.e.UIC,County,State,Variance,etc.) ft. ft. tn•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATF.RLAL.
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Comrnercial Residential Water Supply(shared) 1R:GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fc. 20+ ft. Bentonire Pour(14)501b Bags
Monitoring Recovery
injection Well: et rt
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVF.i;PACK fif applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control n• ft.
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG(attach additional sbeets if necessary).
Geothermal eatin /Coolin Retum Other ex lain under 421 Remarks) FROM To DESCRIPTION(color,hardness sontrock tyM grain size etc.)
0 ft. 23 ft. Brown Clay
4.Date Well(s)Completed: 10-18-22 Well ID# Well#4 23 "' 47 «• Brown Rock
5a.Well Location: 47 ft. 600 rt' Granite
Circle S Ranch ft. ft.
T+
Facility/Owner Name Facility ID#(if applicable) ft. ft. k_,LZ! 144 5„Li
Austin Rd. I Well#4 Monroe 28112 ft. n.
NOV
Physical Address,City,and Zip
Ft. rt.
Union 04-213-010 2I.REMARKS r _ a• r st: ;, tits
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
34.50.603 N 80.33.276
lr—sj- 10-28-22
6.Is(are)the well(s)Wermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing wen: []Yes or JoNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Jf this is a repair,fill nut knomi well conrtrucfimt iri rmation and explain the nature of the cnpy of this record has been provided in the well owner
repair under#121 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 page to provide additional well site details or well
construction,only I GW-1 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
Fm multiple welle list all depfhc if different(example-3@l200'am12@100� construction to the following:
10.Static water level below top of casing: 19 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,ttse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 30oZ 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 Resources Revised 2-22-2016