GW1-2023-02831_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver '.141-AVATER ZONES tk,,%-
Well Contractor Name FROM TO I DESCRUITION
245 331
3002-A
356 tc. 472 541
NC Well Contractor Certification Number
OUTM CASING(for.nultl-casel.',,Wells)'-ORIANFR(if'o
Carolina Well.Drilling FROM To I DIAMETER_L_LMRCKNE8S MATERML
Company Name 0 rt'. 44 1 1,- ra,im in- SDR21 PVC
23-81 A hl 6.1`IN M K CASINO 0 R'-
2.Well Collstructllofi Permit#: FROM TO .1 DUMETER TIUCKNESS MATERIAL
. ermirs(i.e.UIC.County,State,Variance,etc.) ft. i ft.
List all applicable well construction p I In.
3.Well Use(check well use): IL R. In.
Water Supply Well:
FROM TO I DIAMETER SLOT SIZE TMCKKFSS MATERIAL
:]Agricultural []Municipal/Public R In.
3Geothermal(Heating/Cooling Supply) []Residential Water Supply(.single)
f
DIndustrial/Conimercial 13Residential Water Supply(shared) Ift:1GR0UT'`1y;..4'1",d
ohrigation FROM TO I MATERIAL EARILACE6IF24T METHOD&AMOUNT
Non-Water Supply Well: 0rt. 20+11 ft* Benton"Ite Pour(110)501b Bags
3NIonkoring C ecovery h
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery :E3 Salinity Barrier FROM To MATERIAL EA CEMENT AIET11101)
Aquifer Test [3storinwater Drainage
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20i DRILIdNG LOG'(affnch additloiial,shee&if-necessary)
FROM TO DESCRIPTION(color,hardnew,sefl/rock type,grutu size,etc.)
GeothemW(Heating/Cooling Return) n Other(explain under 421 Remarks)
0tc. 6 Brown/Red Clay
:
4.Date Well(s)Completed: 3-30-23 Well ID11 6 1 s) ft. Brown Rock
Sa.Well Location: 19 rt. 600 Grapite F7
Circle S Ranch rt. rt.
Facility/Owner Name Facility M#(if applicable) ft. -ft. APR 2 0 2023
Austin Rd. I Well#3 Monroe 28112 ft. R.
ft. ft.
Physical Address,City,and Lip
Union 04-189-005
County Parcel Identification No.-(PIN)
51b.Latitude and longitude in degreeshidnates/seconds or decimal degrees:
(if well field,one tat/long is sufficient) .22,Certification;
34.81.850 N 80.54.393 4-3-23
6.Is(are)the well(s)foPerrnanent or OTemporary Signature of Ccrdh ell Contractor Date
By signing this form.I hereby certify that the well(s)stur(were)comirucled in accordance
7.Is this a repair to an existing well: [3Yes or WNo with 15A MCAC 02'!C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill(,w k7wirn well corarructiou it formatinn and explain the nature of the cnpy of this reenrd har been prnvided to the well mmer.
repair under#22 remarks section.or an the back of thisfonn. 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,provido additional well site details or well
construction detAils. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NTUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
600 1
0.Total well depth below land surface. At-) 24a. For All Wellsv Submit this form within 30 days of completion of well
For mulople ivel&lint all detrilatfilfferent(exarnple-JW00'and 2@1001 construcdoti to the following:
10.Static water level
I below top of casing: 36 -(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise 1617 Mail Service.Center,Raileiggli,NC 27699-1617
11.Borehole diameter: 6
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above, also submit one copy of this form within 30 days of completion of well
construction to Inc following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1'1636 Mail Service Center,Raleigh,NC 27699.1636
13a..Yield(gpm)_ -5 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: 36OZ completion of dwell construction to'tii I e county health departortent of the county
where construcied.
Form GW-I North Carolina Department of Environmental Quality-DivIsL of Water Resources Revised 2.22-2016