GW1-2023-02833_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14.WATER ZONES`
Wet[Contractor Name FROM TO llFSCRH•TION
ft.
3002-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cas id iiwellsl OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER; THICKNUSS MATERL+IL
Company Name
0 r`' 46 r`' 6114 in. SDR21 PVC
Z3-99A 16ANNER.CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TIHCKNFSS MATERIAL
List all applicable ivell construction permits(i.e.UX,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER S1.OTSME THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 718.'GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We 11: 0 r` 20+ r` Bentonite Pour(13)501b Bags
Monitoring ORecovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge. Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSaliniry Barrier FROM TO MATERIAL I Ebi1 L4CEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necrssarv) _
FROM TO DFSCRTPTION(color,hardness sotl/rock rain size etO
�Geothermal(Hearin /Conlin Return) Other(explain under#21 Remarks
0 r`' 6 ft, Wet Brown Clay
4.Date Well(s)Completed: 4-6-23 Well ID# 6 r`' 12 r"- Brown Shale/Quartz
5a.Well Location: 12 f`' 400 r`' Granita­
Circle S Ranch ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
A
Austin Rd. I Well#4 Monroe 28112 ft• n• U L i
, ft.
Physical Address,City,and Zip
Union 04-189-005
21:RENIAMS,
County Panel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.82.214 N 80.54.333 W
4-7-23
6.Is(are)the well(s)OPernmanent or'Temporary Signature of Certified well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rJYrs or RNo ivith 15A NCAC 02C.0100 or 15A ArCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill our known well cmarruclion infrirmatinn and explain the nature of the copy of this record har been provided to the well ourter.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Totall well depth below land surface: 400 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of-well
For multiple wells list all depths if different(ex unple-3(a,)200'and 2@100� construction to the following:
1.0.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level 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
13a.Yield(gpm) 0 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- 0oz completion of well construction to d a!1county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i