GW1-2022-10590_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name FROM
ft 187 ft
3002-A
219 ft' 240 ft 384,441642 748
NC Well Contractor Certification Number 15.OUTER CASING(for inulti-cased wells)OR LINER(ifa 'licable
Carolina Well Drilling FROMTO DIAMETER THICKNESS MATERL�I
Company Name 0 ft' 145 ft' 61/4 in' SDR21 PVC
16.>INNER CASING OR TUBING,,( eothermal;closed-loo r'`
2.Well Construction Permit#: 22-260 FROM TO DIAMETER THICKNESS MATERIAT.
List all applicable well constn4ction permits(i.e.UIC,County,State,Variance,etc.) ft. fl. in.
3.Well Use(check well use): ft. tt. in.
17:SCREEN
Water Supply Well:
FROM TO DTAMFTER • ST.OTSIZF. TTi1CKNFSS MATF.RIA1.
Agricultural ElMunicipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL qL qn,
Industrial/Commercial ®Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAi. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 O 20+ tt. Bentonite Pour(14)501b Bags
Monitoring CIRecovery ft. ft.
Injection Well:
ft. ft.
..,,Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAWIC PACK ifapplicable)
Aquifer Storage and Recovery ElSallnity Barrier FROM TO MATERIAL FNIPLAI-EMENTMETH(M
Aquifer Test 13Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCRTPTION(color,hardness sell/rock rain sine eta)
Geothermal(Hearin /Coolie Return) rl Other(explain under#21 Remarks
0 ft 10 n' Brown Clay/Shale
4.Date Well(s)Completed: 11-3-22 Well ID# 10 �' 901) ft' Blue Slate
Sa.Well Location: ft. ft.
Rountree Properties -:
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
7901 Concord Hwy.Indian Trail 28079 ft. ft. N
Physical Address,City,and Zip ft. ft.
Union 08-186-004A/B 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.14.755 N 80.53.831 W
�' — 11-14-22
6.Is(are)the well(s)JaPermanent or OTemporary Signature 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 Jallo with 15A NCAC 02C.0100 or 15A ArCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill nut boon well emurnwhon information and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#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 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: 900 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lisr all depths if different(example-3 a1100'and 2(a;100) construction to the following:
10.Static water level below top of casing: 11 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing,use"+" 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 mt pu construction to the following:
(i.e.auger,rotary,cable,direct pushh,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) 15 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: 54oZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016