GW1-2023-02834_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver �44.tvATER-ZONES"
Well Contractor Name FROM TO DESCRIPTION
3002-A 49,67 et. 95 et.
269 fL 293 "' 435 600 1
NC Well Contractor Certification Number 15sOUTFR=CA$JLVG On Triulti casiatwells)'Olt`1:iNFR(iP;a Ucatile)
Carolina Well Drilling FROM TO DIAMETER I I TIHCKNESS MATERIAL
Company Name 0 ft' 45 ft' 6114 'n' I SDR21 PVC
23-24 6.INNER CASING.OR.TUHINC,'`(✓eother'tual'cl6sed
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17i.SCREEN .a.E. .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS f' MATERTAi
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) QRmddential Water Supply(single) ffi ft, iu
Industrial/Commercial ORecidential Water Supply(shared)
hlf ation FROM TO MATERIAL ,.,EMI•LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ ft. Bentonite Pour(8)501b Bags
:)Monitoring Recovery
injection Well:
ft. ft.
__Aquifer Recharge []Groundwater Remediation
°19.'SANDIGRXW..T;TACK,(ifa il6ble
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL FAI LACEMENT METHOD"
Aquifer Test [3Stormwater ft. ft.Drainage -
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.1MRMLINGLOG littach,additionul sheiti if necessarry)
FROM TO ' DFSCRTPTiON(color,hardness sell/rock type,grain size etc)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks)
0 ft• 19 fl. Brown/Red Clay
4.Date Well(s)Completed: 3-16-23 Well ID# 1.9 ft' 675 fl' Granite
ft. ft.
5a.Well Location:
Circle S Ranch ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Austin Rd.I Well#2 Monroe 28112 et, t.
Physical Address,City,and Zip
Union 04-189-005 ,21 REMARILS"
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34,81.966 N 80.54.453 W
��� 4-3-23
6.Is(are)the well(s)QPermanent or OTemporary SilFatare of Certified Well Coa ctor Date
By signing this form,I hereby certify that the well(s)was(were)consirucled in accordance
7.Is this a repair to an existing well: [3Yes or 5&No with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
IfThis is a repair,fill out known well construction information mud explain the nature of the copy of this record has heen pravided to the well owner.
repair under i121 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 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: 675 (it) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths if different(example-3(a3200'and 2()100 construction to the following:
10.Static water level below top of casing: 27 (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) 1 Method of test: Air 24c.For Water Supply&Iniection,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: 400Z completion of well construction tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016