GW1-2023-00712_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor information:
Frankle L. Oliver
WATEXZONFS'
FROM TO 1 DESCRUMOIN
Well Curturactor Name
103 119
3002-A JAI 2OZ3
156 189. 206..233 308324
NC Well Contractor Certification Number -(for.i Will �,j:
rO�
�j 1:115.OUTPRICASING icable):.-,
7 1. FROM I TO 1 DIAMETER MATERUL
Carolina Well Drilling ft.
Company Name 0 rf 45 6 1/4 SDR21 PVC
;:j6.jNNER,CA.SINGj1ORT INC. -":�,'
1.Well Construction Permit#: 22-196 FROM TO 1 D1A11ETER TEmCKNFSsMATERIAL
List all applicable ivell corarmcdon permits(i.e.UIC,County,State,Variance,e1c.) fL In.
3.Well Use(check well use): ft. i ft. In.
N
Water Supply Well: 17.:SCREE FROM TO MARKHR I $T.OT SIZE TMCKW'SS MATFATAT,
:]Agricultural nMunicipal/Public .ft. it. In.
-IGeotbemial(Heating/Cooling Supply) WResidential Water Supply(single) ft la
:]1ndustrial/Cominercial 1311csidential Water Supply(shared) 18 GROUT",
31nigation FROM TO EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20t' Bentorifte Pour(12)501b Bags
nMonitoring C)Recovery &
Injection Well: ft. f ft.
1 Aquifer Recharge El Groundwater Remeditition
Aquifer Storage and Recovery [3Salinity Barrier FROM TO NUTERLAL I EMPUCEA"T METHOD
Aquifer Test E)SIonnivater Drainage ft. ft.
Experimental Technology j3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer
Geothermal(Heating�Cooling Return)) 'Other(explain under 421 Remarks j FROM TO nVISCRTKION(color,hardness,son/rocktype�grain sin,etc.)
0 8 ft. Red Clay
4.Date Well(s)Completed: 11-21-22 Well IDU a 24 Brown Clay
59.Well Location: 24 ft. 3$0 Blue Slate
Roger Walton ft.
n.
Facility/Owner Name Facility MR(if applicable) ft.
2917 Heath Davis Rd.Monroe 28110 et. -ft.
Physicid Address,City,I and Zip ft. ft,
Union 09-253-079
County Parecl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lathong is sufficient) 22.Certification:
35.20.438 N 80.34.102
11-28-22
6.Is(are)the well(s)JOPermanent or oTemporary Signature of Certified Well Contractor Date
By signing lhisjbne,I hereby certify ihaj the welf(s)was(were)consirucled in accordance
7.Is this a repair to an existing well: E]Yes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02.C.0200 Well Construction Standards and 040 a
If this&a repair,fill nut knijim ivell conviruction b1fornw(ion and explain the itaiure offhe c?py of this recnrd haw been provided to the.well owner.
repair under#21 remarks section or on the back Df1h.6forna. 23.Site diagratri.or additional well details:
You may use the back Of this page to provide additional well site details or well
8.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the same the
may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicatd TOTAL NUMBER of wells construction details. Yost
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface- 350 tit-) 24a. For All Wells: Submit this form within 30 days of completion of well
For muiriple iveltv lirt all depths jfdiffiere�nt(example-3@206'awl 2 Willo� construction to the following:
111 Static water level below top of casing: 20 (ft.) blvision of Water Resources,Information Processing Unit,
Iftvarcr level is above casing,use
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For hilection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also sitbiAt one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rutmy,cable,ditCCE pUS14 etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WFLIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Air 24c.For Water Supply &Injection Wells: In addition to sending the,form to
the address(cs)!above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 20oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEnviionmental Quality-Divisi i on of Water Resourm; Revised 2-22-2,016