GW1-2023-02839_Well Construction - GW1_20230420

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver Ia.WATER ZONES
Well Contractor Name FROM TO DFSCRn'TION
3002-A 325 ft 370 ft.
425 fc' 478 ec.
NC Well Contractor Certification Number 15;OUTER CASING(for mtilti-cased`wells)OR LINER(it' livable)
Carolina Well Drilling FROM To DIAMETER THICKNESS MATERLAL
0
Company Name
ft. 45 ft' 61/4 '"' SDR21 PVC
22-447A 16.INNER CASING:OR TUBING'.(etithermal closed-loo') '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cunstntction permits(i.e.UIC,Cuumv,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: I7.SCREEN'
FROM TO DTAMF,TF,R SLOT SUR TMCKNFSS MATF.RTAT,
Agricultural []Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMI LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 20+ ft. Bentonite Pour(12)501b Bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 49.SAND/GRAVEL:PACK Ciro livable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL A I EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG iattach additioual'sheets if uecessarp)
RFROM TO mFSCRTPTTON(color,hardness saillrock rain size etc.)
Geothermal(Hearin Cooling Return) rl O[her(explain under#21 Remarks) 0 It. 13 ft- Brown Dirt
4.Date Well(s)Completed: 1-31-23 Well ID# Well#1 13 If- 24 If- Brown Rock
Granite C.^
f
5a.Well Location: 24 600 t' T
Circle S Ranch ft. ft, x. T <.r'ti-. -•-:
Facility/Owner Name Facility ID#(if applicable) It. ft. APR 2 0 2023
Wolf Pond Rd.Monroe NC 28112 ft. ft.
Physical Address,City,and Zip ft. ft.
Union 04-159-010&011 21.REMARKS _
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:
34.82.527 N 80.53.577 W
2-28-23
6.Is(are)the well(s)mPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)consttvcled in accordance
7.Is this a repair to an existing well: Yes or fallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill am knonn well construction information and explain the nature of the copy of this record has been provided to the well nawer.
repair under#2I remarks section or on the back of thus 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.
dtilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 600 Ut.) 24a. For All Wells: Submit this form within 30 days of completion of well
For-muhiple wells lint all depths ifdifferens(example-3(a1200'and 2@100� construction to the following:
10.Static water level below top of casing: 42 (ft.) Division of Water Resources,Information Processing Unit,
tf water level is above casins,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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&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 well construction to l a county health department of the county
where constructed.
Foan GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016