GW1-2023-02829_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14.-WATER ZONES. � ".
Well Contractor Narne FROM TO I DESCRH•TION
55,68 rt• 76,96
3002-A ft.
102 ff 120 ft. 138
NC Well Contractor Certification Number 15:,OUTRR CASING°(roc multi-cased tvells).OR t;rNFR'(ifia °1[cahle
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERL4I
Company Name
0 ft' 45 ff 6 1/4 in7 I SDR21 PVC
22-398 16:_INNER GA&II!(G nR:TUIIING("eptherinahclosed
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cwnstniction permits(i.e.UIC,County,State,Variance,etc.) f[. ft. iu
3.Well Use(check well use): ft. ft. in.
Water Supply Well: l7,• CREEN.
FROM TO DiAMP.WR Si.OT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Pablic ft. it. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) O. ft. itu
:)Industrial/Commercial E3Residential Water Supply(shared)
Iiri ation FROM TO 11LtTERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(13)501b Bags
:)monitoring EIRecovery ft. ft.
injection Well:
Aquifer RechargeGroundwater Remediation 19.SANK/GRAYF I?RACK fr a oli'c6l'e).
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD �f y
Aquifer Test E)Stormwater Drainage
Experimental Technology E3Subsidence Control
Geothermal(Closed Loop) Tracer =20.DRILLING'LOG(attach additional Aheets if necessar*),,_
Geothermal(Heating/Cooling Return) ;Other(explain under 421 Remarks) FROM TO DFSCRTPTiON(color,hardness,soil/rock type,grain size etc)
0 ft. 23 ft, Red Clay/Dirt
4.Date Well(s)Completed: 3-6-23 Well ID# 23 ft. 200 ft' Granite
ft. ft.
Sa.Well Location:
RF Property Holdings LLC
Facility/Owner Name Facility ID#i(if applicable)
2612 Plyler Mill Rd. Monroe 28112 Lot#6 ft. rt. APR 2 Q 2023
Physical Address,City,and Zip
ft. ft.
Union 04-192-001G ta1::REM=�Rxs 1"
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one far/long is sufficient) 22.Certification:
34.55.758 N 80.34.702 W
4-3-23
6.Is(are)the well(s)JOPermiment or OTemporary ignature of CemfiR Well Contractor Date
Be signing this farm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JoNo with 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Consmction Standards and that a
1f this R a repair,fill out known well conaruction information and explain the nature of the copy of this record hay been provided to the well owner.
repair under#21 rernarky section or on the back a,f 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 wel I
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 UQ 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple weliv Art all depths if different(e)rample-3(ag200'mud 2@)l construction t0 the following:
10.Static water level below top of casiug: 18 A) Division of Water Resources,Information Processing Unit,
If water level is above casir{q,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'forin 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
132.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit jore copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12GZ 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 I Revised 2-22-2016
I I
i