GW1-2023-00713_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Tnfor,natiom
Frankie L.Oliver F":14;WATER20NFS' f k3
FROM TO I LESCHn'TION
Well Cuntractur Natrre
.' 107 tt. 115 ! n.
131 rf 134 ; rt' 143 154 1 B3 190
NC Well contractor Certification Number �y rtnq� `15'OU7ER?CASiNG3fFortntillieasedivuPl's:ORi:INFitF(iPa- 'lliable)"
Carolina Well Drilling J�'` (l1L FROM TO `I DIAMETER TMCKNK4S MATERLkL
CumpauyName ..',j t!t':, 0 fL 45 n' 6 1/4 t"' SDR21 PVC
1f,���•i-:' 1,f16 IN AWCASING;OR_TUB][NG;( eotherinetclosed•too ;.
22-359 '�t;va, ��" FROM I TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permft4:
List all applicable well construction pennits(i.e.U)C,County,State,Variance,etc.) rl. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17i SCREEN r ';i. :y
pP Y FROM TO i I THAMFTFR I SLOT S17E ITRTCKNRSS MATFRTAT.
Agricultural [3Municipal/Public ft. fL in
Geothermal(Heathig/Cooling Supply) GIResidential Water Supply(single) ft. �, in.
Industrial/Cotmnercial E311esidential Water Supply(shared)
I[tl atIDIl FROM TO 1 MATERML Fd[H'LACE11tHNTMETHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20+1 ft.. Bentonite Pour 13)501b Bags
71
Monitoring Recovery ft. a.
13
injection Well: ft. ft.
Aquifer Recharge `®Grotmdwater.Remediation
;197;SAhblGRAYF.ia'PACKfIf;a "1ti�altle' F'�'+ �. :' .a :: ,;';, s � �fi;rat�a;
Aquifer Storage and Recovery E3Saliniry Barrier FR11M TO t I M,&TERUL EMPLACEMENT METHOD
Aquifer Test [3StonmwaterDrainage
Experimental Technology [3Subsideuce Control
Geothermal(Closed Loop) [3Ihacer 2101DRIDLINGILOG4attach'uddltiotial'slieets if
Geothermal(Heating/CoolingReturn Other(explain under 421 Remarks FROM TO DFSCRTT'TiOW color,hardness soNroc lr ,ale sloe etc 0 ft, 4 H. Brown clay
4.Date Well(s)Completed: 11-14.22 Well1Dll 4 ff 200 n' Blue Slate
ft. it.
5a.Well Location:
rt. rt.
Trent Linville
Facility/Owner Name Facility lD@(if applicable) ft, ft.
3710 Baucom Manor Rd.Monroe 28110 rt: n.
ft. n.
Physical Address,City,and Zip
'Union 08-045-021
•':21i'RE'M�RKS:��", � "'�, Fit t :. r�•.y; #:+
County Piurel Identifimtion Nu.(PIN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(ifwell field,one lat/long is sufficient} 22._Certification:
85.60.963 N B0.25.957 �y 11-28-22
Signature of Certified Well Contractor Date
6.Is(are)the well(s)jaPermanent, or ElTemporary
19y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�Ycs or �No with 15A NCAC 02C a1100 or 15A NCAC 02C.0200 Well Construction Standards pritl that a
7.Is this a repair to an exislhrg well:
If illis is a,rotar,fill out'kmn,rm well conuructinn.it fornmrion aml eaplairr the ngmre of the copy nJtlrtt record het heen provided rn the well mtwer.
repair tinder k21 remarks section or on the back of this fonn. 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 IINSTAVCTIONS
I.
9.Total well depth below land surface: 200 UQ 24a. For All Wells: Subtmit this form within 30 days of completion of well
For multiple ivO&lice all depths fdiijlerent(e�:mple-3@200'and 2@100� construction to the following:
10.Stake water level below top of cashtgd 21 (ft.) Division of Water Resources,Ldorttration Processing Unit,
]f water level is above casing,ase"+" 1617 Mall Service Center,Raleigly NC 27699-1617
I
11.Borehole diameter: 6 (in.) 241).For Infection Wells: In addition to sending the form to the address in 24a
Alr Rotary above,also subs ,t one copy of this form within 30 days of completion of well
12.Well construction method, construction to th following:
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELD ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpin) 25 Method of test: Air 24c.For Water!Supply&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 120Z completion of well construction to the county health department of the county
Where constructed.
}
Aorm GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016