GW1-2023-00707_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
I
Frankie L. Oliver ,14: VATER20N S ,:;
Wen Contractor Name FROM TO I DESCHII'TION
3002-A
317 f` 350 f�
NC Weil Contractor Certification Number �' r 378 f` 431 f�' 459 481
Ci
C b <r. `L ^^ l5.0UTVkCASiNG ffdr inultt•cased,ivelis)OR I INF.R(lf n' licable)
Carolina.Well Drilling FROM TO ; nlAntETER TIHCKN&SS MATEUkl,
n- I 9f19� 0 n' 51 f�' 6 1/4 I SDR21 PVC
n i-7.
Company None
:''16. NNER;CA,4N.f,OR TUBIIVG.( eothermal closed•loo'i�"
2.Well Construction Peruniti►: 22-129 . FROM TO I DIAMETER THICKNESS MATERW
List all applicable well cunstniction permits(i.e.UIC,Cuuno,,Sial4i% 'riante,etc.) ft. it. Its.
3.Well Use(check well use): rt• �`' In.
Water Supply Well: M SCREEN l., e - :.:.;
FROM TO I DIAMETER SrOTSI7F. TTiTCKNFSS MA7FRTA1.
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ff ft.! in.
Industrial/Commercial E]Recidential Water Supply(shared) 18'GRUTIT { r
hTi dtion FROM TO i MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0 r` 51 In' Bentonite Pour(20)501b Bags
Moaitornmg Recovery ft. ;ft.
injection Well: ft. i ft.
Aquifer Recharge ®GroundwaterRemediation
19:SANDIGRAVEi BACK(ifa ltcable->:•'.;.
Aquifer Storage and Recovery 13Salinity Barrier FROM TO I 51ATERT:IL I EMPT AI,EMENT MEMO '
Aquifer Test E3StonmwaterDra`inage ft. ft.
Experimental Technology E3Subsidence Control it, i ft.
Geothermal(Closed Loop) Tracer 20.'DRILliINGII:OG?(attnclinddltlonal'aGcetsiriiecessA ):`:
E7f
To I DFSCRTPTION(color,hardness,sottfrock t rain size,etc.,
Geothermd(Heating/Cooling/Conlin Return) !Other(explain under#i21 Remarks
17 rt. Red Clay
4.Date Well(s)Completed: 11-29-22 Well ID# 5001f`. Granite
ft.
Sa.Well Location:
Pedro Trim Construction, LLC rl, n.
Facility/Owner Naiue Facility IDP(if applicable) n• fl.
1327 Stack Rd. Monroe 28112 Stack Road Estates Lot#4 rt. et.
Physical Address,City,and Zip ft ft
Union 04-114-0101< �`zI:REM�RxS,.;=�� �" �• r
County Patuel Identification No.(PIN)
"Full length grout as required by permit
5b.Latitude and longitude In degreeshulnutesfseconds or decimal degrees:
(if well field,one lathong is sufficient) 22.Certification:
34.54.499 N 80.30.584 W
'" 12-12-22
6.Is(m•e)the wells)JoPermaneut or Temporary Signature of Certified Well Contractor Date
By signing this forms I hereby certify drat the well(s)was(were)constructed in accordance
7.Is this a repair to an eAstiug well: QYes or JoNo ivith 15A NCAC 02Ci.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
IJthis is a repair,fill out lmuniai well crinstrucfinn infnrniation snot riplain the auntie aJrhe copy of this record hyts been provided rd the well rumor.
repair under#21 remarks section or on the back of this form. i
23.Site dingram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use theiback of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction duaiIs. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 500 (ft-) 24a. For All Wells: Submit this form Within 30 days of completion of well
Por multiple ive/is lien all depths iirdi,Ijerent(example-3@200'and 2@100� construction to the following:
to.Stacie water level below top of casing' 27 (ft.) Divlsltin of Water Resources,Information Processing Unit,
If scaler level is above casing.Ilse"+ 127 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter_: 6 (in.) 241).For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also subthit 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.) I :.
Division of rater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 f
36 Mail Service Center,'Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Alf 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: 30oZ completion of well construction to the county health department of the county
where construe ed.
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016
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