GW1-2023-00709_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14..WATER ZONES,
FROM TO DFSCRH'TION
Well Contractor Name
122 fc. 149 n.
3002-A �: - l�l�=r <� a - •%
190
NC Well Contractor Certification Number I �• 15.OUTER CASING(for multi-cased welts)OR LINER(if a licable)
Carolina Well Drilling JAN Z023 FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 rt. 97 6 114 in' SDR21 PVC
22-344•ri�'�"' r '.16.INNER CASING OR TUBING(geothermal closed-loop) '
2.Well Construction Permit It: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. In.
17.SCREEN
Water Supply Well:ppye FROM TO DTAMF.TER SLOT SIZE THTCKNF.SS MATF.RTAL
Agricultural E)Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
fiidustrial/Cominercial E3Residential Water Supply(.shared) iR.GROUT
Irri anon FROM TO MATFurnr. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(21)501b Bags
Monitoring Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge [:]Groundwater Remediation
79.SAND/GRAVF.T.PACK(if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO I M.i,TERIAL EMPUXEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) !Other(explain under 421 Remarks) FROM TO DFSCRTPTTON(color,hardness solUrock rain sloe etc
0 It. 12 ft. Orange Clay
4.Date Well(s)Completed: 12-2-22 Well ID# 12 "' 31 fl' Brown Clay
5a.Well Location: 31 ft. 85 rt- Gray Clay/Slate
Southern Interior Design Corp. 85 fi' 200 ft, Blue Slate
Facility/owner Name Facility III#(if applicable) ft. ft.
Lanes Creek Township Farms Lot#4 Marshville 28103 et. ft.
Physical Address,City,and Zip
rr. ft.
Union 03-114-002 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar/long is sufficient) 22.Certification:
34.49.023 N 80.23.942 W _
12-22-7.2
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified well Contractor Date
By signing this fann,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out larnvsn well construction hifornwtion and explain the nature of the copy of this record has been provided to the well naner_
repair under#ill 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: 200 Ut-) 24a. For All Wells: Submit this form within 30 days of completion of well
For inultiple welk list all depths if different(example-3(a3200'and 2L100� 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 casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 1
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) 6 Method of test: Air 24c.For Water Supply&Infection 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- 12oZ 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 Resources, Revised 2-22-2016
i