GW1-2022-10589_Well Construction - GW1_20221122

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor information:
Frankie L. Oliver 14.WATER ZONES'
FROM TO DESCRH'TION
Well ConQauot Name
115 ft. 136 ft.
3002-A
148
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased l vells)OR i,iNF.R iFa"livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERUL
0 ft. 85 n' 61/4 rn' 1 SDR21 PVC
Company Name
22-383 16.INNER CASING,OR TUBING,(geothermal closed-loop)
2.Well Construction Permit 4h FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cunsirnction permits(i.e.U1C,CuunM State,Variance,etc.) ft. fl. in.
3.Well Use(check well use): ft. fl. in.
JN�
er Supply Well: 17.SCREEN
FROM TO DTAMFTF.R SLOT SUR THICKNESS MATF.RTAT.
gricultural ®MunicipaUPublic ft. IL in.
eothermal(Heating/Cooling Supply) Residential Water Supply(single) n. fL in,
dustrial/Cormnercial Residential Water Supply(shared) 1g,GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-Water Supply Well: 0 ft. 20+ ft. Bentonire Pour(21)501b Bags
onitoring ®Recovery ft. ft.
ction Well: ft.
quifer Recharge 13GroundwaterRemediationa9.SAND/GRAV,F.I,PACK(iFa liable)
quifer Storage and Recovery Salinity Barrier FROM TO M4XERUL EMPLACEMENT METHOD
quifer Test Stormwater Drainage
perimental Technology Subsidence Control n. n.
eothermal(Closed Loop) Tracer 20.DRILLING LO'G(attachadditional sheetsifnecessaFROM TO DFSCRTPTTON(color hardness sell rock rain size etc)
eothermal(Heating/Conlin Return) Other(explain under#21 Remarks
0 of 18 ft' Red Clay/Quartz
4.Date Well(s)Completed: 10-20-22 Well ID# Well#5 18 ft- 74 ft. Brown Clay/Shale
5a.Well Location: 74 rt' 300 ft' Granite
Circle S Ranch fc. ft. p
Faciliry/Owner Name Facility ID#(if applicable)
Austin Rd. I Well#5 Monroe 28112 ec. n.
Physical Address,City,and Zip ft. ft. T 11T I)rkti
Union 04-213-010 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.47.133 N 80.37.164 W
10-28-22
6.Islam)the wells)faPernranent or [1 Temporary Signatme of Certified 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 WNo with 15A NCAC 02C.0100 or 15A AICAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infnmatinn and explain the nature of the copy of this record hav been pmvided to'the well owner.
repair under#21 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 wel I
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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welly licr all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 28 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casin,G,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniectiou 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 Mait Service Center,Raleigh;NC 27699-1636
13a.Yield(gpm) 31 Method of test: Air 24c.For Water Supply&Injection 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: 18Oz 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 Resourcel
S Revised 2-22-2016