GW1-2023-00762_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14:;WATER ZONES:'..
Well Contractor Nazne FROM TO DESCRH'TION
88 fc 107 ft.
3002-A
113 ft' 118 ft. 121 137,148,158
NC Well Contractor Certification Number 15:.OUTER CASING(for multi-cased'welli);OR LINER(if=a livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERL4L
Company Name 0 ft. 49 ft' 6114 in' SDR21 PVC
22-134 A6.INNER CASING-OR TUBING,(ea"tliettnat closed-lao)"'- -
2.Well Construction Permit It:
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft.
Water Supply Well: YR,SCREEN
FROM TO DTAMRTRR S LOT SIZE TATCRNRSS MATF.RTAi,
Agricultural [:]Municipal/Pubhe ft. ft. in.
Geothermal(Heating/Cooling Supply) 5&Residential Water Supply(single) ft. g,
Industrial/Commercial QResidential Water Supply(shared) 15:GROUT `
IITi atlon FROM TO I1fATERIAL EbH'LACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 fc. 20+ ft. Bentonite Pour(20)501b Bags
Monitoring ORecovery ft. ft.
injection Well: ft ft
Aquifer Recharge []Groundwater Remediation
SAND/GRAVET..PACK(afa livable)', '
Aquifer Storage and Recovery Salinity Barrier FROM TO 11LATFRTAL EMFL4CEMENT METHOD
Aquifer Test CJStormwater•Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG'lattach additional sheets if necessary)
Geothermal (Heating/Cooling Return) n Other(explain under 421 Remarks) FROM TO DFSCRTPTTON color,hardness sotlhock type,gratu size etc.)
0 ft. 36 ft• Red Clay
4.Date Well(s)Completed: 11-9-22 Wen ID# 36 ft' 175 ft' Granite
5a.Well Location: ft. ft.
Persis-Nova Const. Inc. et. n. ;'.
Facility/Owner Name Facility ID#(if applicable)
4558 Chanel Ct.Concord 28025 ft. ft. jAN 1 2 2023
Physical Address,City,and Zip ft. ft. I Gi i'ie+eryC1 �iC.C;v�•3dr� l l
Cabarrus 55562658440000 ,21 REMARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshuiuutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.17.532 N 80.30.105 W
12-1-22
6.Is(are)the well(s)JOPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an emdsting well: QYes or RNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill our krunvn well construction inro oration and explain the nature of the copy of this record has been provided to the well owner.
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 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: 175 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a OU'and 2@100� construction to the following:
10.Static water level below top of casing: 23 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,ase"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iujection Wells: In addition to.;ending the form to the address in 24a
Air Rotary above, also subunit one copy of this form within 30 days of completion of well
12.Well construction cable, 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) 50 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- 12oZ 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