GW1-2023-02910_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14:WATER ZONES
FROM TO DESCRH'TION
WellCunuacturName 56,74 ft. 87 Cl.
3002-A
94 fc. 105
NC Well Contractor Certification Number M OUTER CASING(for multi-c'ased'wells)OR iANF.R(if ap licable)
Carolina Well Drilling FROM TO DU METER;` THICKNE45 MATERLAL
Company Name 0 ft' 153 ft' 1 6114' in. SDR21 PVC
22-429 '16.INNER CASING OR TUBING( eotli&mal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.)
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN = `
FROM TO DIAMETER SLOT SIZE THICKNFSS MATERIAL
Agricultural rIMunicipal/Public ft• ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. g•
htdustrial/Commetcial E3Residential Water Supply(shared) P 18:GROUT
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(20)501b Bags
Monitoring DRecovery ft. ft.
injection Well:
Aquifer Recharge []Groundwater Remediation
19 SAND/GRAW..i,PACK Of a licabl'e)
Aquifer Storage and Recovery Salinity Barrier FROM TO NUTERIAr EMPLACEMENT METHOD
Aquifer Test []Stannwater•Drainage
et. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG.(attach additional sheets if necessary)
FROM TO DFSCRTPTION(color,hardness sollfreck rain size etc)
Geothermal(Hearin /Conlin Return) i Other(explain under#21 Remarks)
0 ft. 3 ft, Red Clay
4.Date Well(s)Completed: 3-7-23 Well ID# 3 ft' 28 ft- Brown Dirt/Rock
5a.Well Location: 28 ft. 200 ft' Granite r •.
RF Property Holdings LLC ft. ft. ' -I.—
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2618 Plyler Mill Rd. Monroe 28112 Lot#3 fc. ft.
Physical Address,City,and Zip ft. ft. i'J
Union 04-192-001 D 21.REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
34.55.663 N 80,34.700 W ^� '
-�[ 4-3-23
6.Is(are)the wells)jOPerntanent or E)Temporary Signature of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)conslrucled in accordance
7.Is this a repair to an existing well: E]Yes or [?No with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill out known well construction infnrmatinn and eaplain the nature of the copy of this record har been provided to the well owner.
repair under#121 remarks section or on the back of this farm.
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-I 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: 200 M-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths if different(example-3(a3200'atul2(a1160D construction to the following:
10.Static water level below top of casing. 30 (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 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.) i
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: Air 24c.For Water Supply&IDiection 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: 120Z completion of well construction to the county health department of the county
where constructed. 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016