GW1-2022-10600_Well Construction - GW1_20221122

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WELL CONSTRUCTION RECORD (GW-1) For Internal Us6 Only:
1.Weil Contractor Information:
Frankie L.Oliver a:tv.►Tlti7() Syi t .,ti c . it
Well Cuntractur Name FROM I TO I DESCRIPTION
101 n. 116 ft'
3002-A
132 n- 149 rt' 170 216'227 275
NC Well Contractor Certification Numberfj�fpp j1'Bg tr li ttt a llS i(1TiftaiiVFtit_ (tii
Carolina Well DriAing FROM TO_ DIAMETER THICKNESS MATERIAL
Company Name 0 rt' 83 t1. 61/41ln' SDR21 PVC
368653 . ZIHA
2.Well Construction Permit#: FROM TOETER THICKNESS MATERIAL
List all applicable ivell cunsdxction pen nits(i.e.VIC,Comte,State,Variance,etc.) ft. In.
3.Well Use(check well use): tt. In.
� GWater Supply Well: AllFROM TOR S10TSi7F TMC MATF.RTAI
Agricultural ®MunicipaUPublic ft. ft. fa
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. n. in.
IndustriaUCommercial Residential Water Supply(shared) g' RO. y ::
Irrigation FROM TO MATERIAL t21ti'LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n' 20+ n' Bentonite Pump(6 501b Bags
Monitoring Recovery ft. ft. Pour 1 501b Bag
injection Well: ft. ft.
Aquifer Recharge ®Groundwater Rernediation
10. ;t; /Git'_NT1p"�;K F; 1►lredt' �z.=�;� '"`' x��'' �. '
Aquifer Storage and Recovery [3Salinity Barrier FROM I TO MATERIAL EMP[ACEMENT MMOD
Aquifer Test [3Stnrrnwater Drainage ft. I ft.
Experimetnai Technology [3Subsidence Control ft. I ft.
Geothermal(Closed Loop) 13Tracer )Zb:fil L`tiN ' .a a Otsi8dltltiilit) lie k tfli a ti'd Y sY`, 'rn''r
Geothernal 04ealingtCooling Return) Other ex lain under#21 Remarks FROM TO DFSCRTPTiON cAar,hardn aot0rock to stm etc
0 ft. 1 n' Red Clay
4.Date Well(s)Completed: 10-21-22 Well ID# 12 n' 5 n' Brown Dirt
Sa.Well Location: 52 ft. 7 fl. BrownoC , �s,.•'e c I)
Brandon Mullis 75 n' 300 n- Blue Slate
Facility/opener Name Facility ID#(it applicable) D• j n. O L
18835-A Old Mill Rd.Locust 28097 ft. n. 1 In
Physical Address,City,and Zip
n i fT t. f y
Stanly 138440 21;RE11t:A ^'7 *. .775 R, + t M
County Parcel Idcntifiwtiun No.(PIN)
5b.Latitude and longitude In degreesIminutes/seconds or decimal degrees:
(if well field,out lat/long is sufficient) 22.Certification?
35.31.284 N 80.34.559 W
11-11-22
6.Is(are)the wells)&aPermanent or [3Temporary Sigmttue of Ctatifi d Well Contractor Dace
By signing this forth,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eldsting well: ®Yes or SINo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill out bech n is-ell construction itifon nuuinn and explain the nature of the copy of this record iras been provided to the well ogress.
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 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 J�SMUCTI
9.Total well depth below land surface. 300 (ft-) 24a. For All yells: Submit this form within 30 days of completion of well
For multiple ivelli list all depths if different(example-3@)200'and 2@1001 construction to tie following:
In.Static water level below top of casing: 46 (ft.) D1vislqn of Water Resources,Information Processing Unit,
If water level is above raring,use"+" 1 417 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (in.)
246.For bdon Wells: In addition to carding the form to the address in 24a
Air Rotary above, also sub it one copy of this form within 30 days of completion of well
12.Well construction method: construction to t te following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY' 1 6 Mail Service'Center,Raleigh,NC 276994636
13s.Yield(gym) 9 Method of test: Air 24c.F r Agte Su 1 &I 'ection 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: 180Z completion of well construction'to the county health department of the county
where construct . i
Form GW-I North Carolina Department of Environmental Quality-Divisic n of Water Resources Revised 2-22-2016
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