GW1-2023-01793_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3002-A 48,73 r`• 105 it-
KC r`' 137 rt. 140,178 215 256,295,417,462,525 541
NC Well Contractor Certification Number15.OUTER CASING(for multi-cased wells)OR LINER(if a icable)
Carolina Well Drilling FROM TO DIAMETER HI TCKNESS MATERIAL
Company Name
0 r`' 45 r`' 6114 i SDR21 PVC
22-364 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List an applicable well cunsnuction permits(i.e.UIC,County.State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SUE THICKNESS MATFRr U.
Agricultural []Municipal/Pubhc n. (L in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(Single) ft. ft.
Industrial/Commercial []Residential Water Supply(Shared)
1R.GROUT
hTl ation FROM 10 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20+ ft. Bentonite Pour(12)501b Bags
Monitoring EIRccovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge (itoundwater Remediation 19,SAND/GRAVEL PACK(if appliceble)
Aquifer Storage and Recovery Q Salinity Barrier FROM TO I M STERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage
ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG lataach additional sheets if necessary)
r-lFROM TO DFSCRTPTION(color,hardness soil/rock rain size etc.)
Geothermal(Heating/CoolingReturn) Other(explain undo 421 Remarks
0 f`' 3 n' Brown Clay
4.Date Well(s)Completed: 12-29-22 WeII HM 3 ft. 13 ft.
Brown Clay/Shale
5a.Well Location: 13 f`' 650 r" Blue Slate
Mark&Tanya Snead ft. ft.
Facility/Owner Name Facility ID#(if applicable) rt• ft. i .r
6402 Landsford Rd. Marshville 28103 n• ft• i--. a ~-•
Physical A"ess,City,and Zip ft. ft.
Union 03-108-015 21.REMARKS —
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.51.561 N 80.23.370 W
1-19-23
6.Is(are)the well(s)UPerteanent or OTetnporary tgnature 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 erdsting well: 13Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If thit&a repair,fill out bvirva well cnnatruction information and explain the nature tifthe copy of this reenrd her been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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: 650 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple welit list all depths if different(example-3(a}200'and 2W00� construction to the following:
10.Static water level below top of cashrg: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rating,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,rotarryy,,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
139.Yield(gpm) 5 Method of test: Air 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type- 70%HTH Amount: 38oz completion of well construction to the county health department of the county
where constructed.
F.u u t.R'-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016