GW1-2023-02842_Well Construction - GW1_20230420

WELL CONSTRUC`7CION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 'a4:HATER ZONES
Well Contractor Name FROM TO' ! WiSCRUMON
3002-A 151 fc• 283 cc•
471 rt. ft. I
NC Well Contractor Certification Number T5;.OITTFKCASTNG`(for tiulH�cesed'�vdl's OR'T,INFR'ir'a'licabte)'
Carolina Well Drilling FRt►M TO i DLOIETF.R THHCKNESS MATERIAL
Company Name - 0 fit. 46 n' 6114 'in' SDR21 PVC
23-15 h'TNNU R CASING'QR=TUBING. eothertndl closed laa )'^:
FROM TO I DUNIET TIBCKMS
2.Well Construction Permit it ER MATERIAL ,.•
List all applicable ivell construction permits(i.e.UIC,Coun(v,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fit. [t. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTS17,F. THICKNESS 11ATF.RTAL
Agricultural 13Municipalt'Public ri. iL in.
i Geothermal.(Heating/Cooling Supply) OResidential Water Supply(single) IL it. in.
Industrial/Colmnercial E311esidential Water Supply(shared) ,18.GROUT i
Irri ation FROM TO MATERIAL EhIPLACEhIENT hIETHOD&AhIOUNT '
Non-Water Supply Well: 0 fit. 26+ tt• Bentonite Pour(9)501b Bags
Monitoring Recovery fit. it.
injection Well: fit. Tt.
Aquifer Recharge ®Groundwater Remediation
19s;6ANO/GRAUF,L:PA"GKlif.dittcali7e. ''" "" '
Aquifer Storage and Recovery [3Saliniry Barrier FROM TO i XALTERIAL EMPLACEMENT METHOD
:)Aquifer Test ®Stormwatet•Drainage
ft. l't.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20:DRILLING I OGaattach addi0uirol'sGeets if iiecessti )::
Geothermal eatin /Coolin Return) 00ther(explain under 4121 Remarks) FROM TO nFSCRTPTIOx color,hardness sollirack t In stra etc
0 rt. 8 n. Red Clay
4.Date Well(s)Completed: 1-18-23 Well ID# 8 fc' 660 ft. Blue Slate
5a.Well Location: ft.
CMH Homes Inc.
Facility/Owner Name Facility W#(if applicable) fit. fl. 1
5814 Medlin Farms Rd.Monroe 28112 Medlin Farms#I34B ft. n.
Physical Address,City,and Zip
Union 03-159-074
County Pnrrel Identification No.(PIN)
5b.Latitude and longitude in degrees/ininutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
34.82.924 N 80.43.913 W
2-14-23
6.Is(are)the well(s),oPermanent or ElTemporary ignature of Cerpfied Well Contactor' Date
$v signing this form.I hereby certify that the well(s)it-as(were)constructed in accordance
7.Is this a repair to an eMsting Well: nYes or.JoNo with 15A NCAC 02C,0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill nut brown ir'ell construction information am]explain the nature of the cdp)•njthis record has heen provided to the well on-ner.
repair under#21 remarks section or on the back of this fort.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/Dl'T or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror•rrruldple wells ha all depths ifdiBeretu(ex<truple•3(aJ 00'aml 2 a@1001 construction to the following'
10.Static water level below top of casing: 18 (ft.) Division of Water Resources,Information Processing Unit,
IjwaJcrlrvel is about eosin,¢•use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Infection Wells: In addition io send ng the farm'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 276994636
13a.Yield(gpm) •5 Method of test: Air 24c.For Water Supply&Infection Wells: In addition to sending the form to
the addresses)labove, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 36oZ completion of well construction,tol the county health department of the county
where constructed.
E
From GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016