GW1-2023-01792_Well Construction - GW1_20230223

WELT. CONSTRUCTION RECORD (GW-l) JT'�C 0111y
1.Well Contractor information:
Frankie L. Oliver 14.WATER ZONES
FROM TO timckil"HON
Well Cunnac[ur Name
87 rt. 112 rt.
3002-A 118 r`. 135 rt' 143,176,188
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a icable)
Carolina Well Drilling FROM TO DIAMETER T THCKNESS MATERIAL
Company Name 0 rt' 86 ft' 61/4 In. SDR21 PVC
22-468 16.INNER CASING OR TiJBING(geothermal closed-loop)
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cunshueuon permits(i.e.UIC Cuuno,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT Si7.F. THICKNESS MATFRTAL
Agricultural QMUnicipal/Public fl, ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. fL is
Industrial/Commercial E]Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rr' 20+ n- Bentonite Pour(185)501b Bags
Monitoring Recovery
injection Well: [t ft —
Aquifer Recharge QGroundwater Remediation 19.S.AND/GRAVF.f,PACK(if applic ble)
Aquifer Storage and Recovery aSatlnity Barrier I FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG tattach addltional sheets If necessan')
FROM TO DFSCRTPTION Icnlnr,hardness wiltr-k t� ,grain size etc.I
Geothemlal(Heating/CoolingReturn .Other ex air under 421 Remarks —
0 ft. 33 ft. Brown Sandclay
4.Date Well(s)Completed: 1-9-23 Well ID# 33 r" 78 ft. Brown Sandstone/Rock
5a.Well Location: 78 ft. 200 r"- Granite P. 1
Amanda Jarrell rt. ft. t .y
Facility/Owner Name Facility ID#(if applicable) ft. ft. — n
1326 Longleaf Ct.Matthews 28104 Providence Place Lot#61 ft. ft. '
Physical Address,City,and Zip ft. ft.
Union 06-063-112 21.REMARKS —
County Parcel Identifiuniun No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees: —
(if well field,one lac/long is sufficient) 22.Certification:
35.10.575 N 80,43.129 1V
—� 1-19-23
6.Is(are)the well(s)UPermanent 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 existing well: ©Yes or 5allo with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
if this it a repair,fill out blown well construction infrnmatinn and eaploin the nature of the copy of this record has been pmvided to the well owner.
repair under#21 remarb section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeMPT 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 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all deptks if d;((erent(e uunple-3(a)200'and 2(g100� construction to the following:
10.Static water level below top of casing: 40 00 Division of Water Resources,Information Processing Unit,
If water bevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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
13s.Yield(gpm) 17 Method of test: Air 24c.For Water Supply dt Injection Wells: In addition to sending the firm 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