GW1-2023-00761_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14.WATER ZONES'- -
Welt Contractor Name FROM TO DESCRIPTION
3002-A 46 ft. 247 n.
254 ft' 267 fc.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR T.TNER(if a licable
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERLAI,
Company Name 0 rt' 45 rf 61/4 In' SDR21 PVC
ZZ-O64 16:INNER CASING OR TUBING;( eothrrmal closed-loop)
2.Well Construction Permit It: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well contraction permits(i.e.UX,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DTAMFTE,R ST.OT STU,, THICKNESS MATF.RTA
Agricultural QMunicipal/Public ft. it. is
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft. fr. in.
Iridustrial/Cominercial OResidential Water Supply(shared)
IR.GROUT
Irri ation FROM TO MATERIAL FAITLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff. 20+ ft. Bentonite Pour(11)501b Bags
:)Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
ly.SAND/GRAYF.T,PACK(if applicable)
'
Aquifer Storage and Recovery nSalinityBarrier FROM To MaTERL4L E11S1L4CEMENTMETHOD
Aquifer Test ElStormwatet•Drainage
Ft. ft.
Experimental Technology Subsidence Control ft. ft.
_i Geothermal(Closed Loop) Tracer 20.DRILLING'LOG(attach additional sheets if.necessary)„ ;
FROM TO DFSCRTPTION(color hardness sollfrock t wale size etc.)
Geothermal(Heatin /Coolie Return) Other(explain under 021 Remarks)
0 ft. 38 ft, Brown Clay/Rock
4.Date Well(s)Completed: 11-4-22 Well ID# 38 ft• 275 ft- Granite
5a.Well Location:
Joshua Ellington
Facility/Owner Name Facility ID#(if applicable) ft. ft. N 71
1063 Ben Black Rd.Midland 28107 IV
Physical Address,City,and Zip ft. ft. f n"f i•r s :+'r_;5.�s. _•::•� t r
Cabarrus 55335606030000 21.REnfARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/nrinutes/seconds or decimal degrees:
(if well field,one lac/long is sufficient) 22.Certification:
35.12.521 N 80.33.248 W
� 12-1-22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify;hat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or JoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this fa a repair,fill our known well construction information and explain the nature of the copy of this record hoe been provided to the well oumer.
repair tinder#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-1 is heeded. 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: 275 (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells liar all depths if different(example-3(Q;200'a,td 2 @100D construction to the following:
10.Static water level below top of casing: 33 A) Division of Water Resources,Information Processing Unit,
If walcr level is above casht•S,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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) 24 Method of test: Air 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- 18oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016