GW1-2023-02911_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information: j
Frankie L. Oliver 14:WATER-ZONES,
FROM TO DESCRH'TION
Well contractor Name
3002-A 87,91 f[. 111 ft.
115 «' 124 «
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased'welIs)OR1.INFR(if;a livable)
Carolina Well Drilling FROM TO DIAMETER i THICKNESS MATERIAL
Company Name
0 ft. 82 ft' 61/4, '°' SDR21 PVC
22-428 16.INNER CASING OR TUBINf,,`(eothennal closed•loo') ,
2.Well Construction Permit#; FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
3.Well Use(check well use): ft. ft. I in.
17.SCREEN.
Water Supply Well: ..FROM TO DIAMETER ST.OTS17.F. THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) it ft.
Iudustrial/Cominercial Residential Water Supply(shared) 1S,GROUT "
-Irrigation FROM TO MATERIAL EDH-LACEMENT METHOD&AMOUNT
Non-Water Supply Well: O rt. 20+ rt. Bentonite Pour(26)501b Bags
:)Monitoring Recovery
injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
ly..SAND/GRAW.T'PACK(if a livable
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPr.ACEMENT METHOD4
Aquifer Test [3Stommvater Drainage
ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer '20.DRILLING LOG(attach additional sheets if uecessa'.)
FROM TO DFSCRTPTTON(color,hardness sell/rock type, rain size etc)
Geothermal(Heating/Conlin Return) i Other(explain under 421 Remarks)
0 ft. 7 rt. Red Clay
4.Date Well(s)Completed: 3-8-23 Well ID# 7 ft' 29 ft' Brown Dirt/Rock
5a.Well Location: 29 "' 200 ft' Granite
RF Property Holdings LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) -
2616 Plyler Mill Rd. Monroe 28112 Lot#4 et. et. APR 2 0 2023
Physical Address,City,and Zip
ft. ft.
Union 04-192-001 E 21.REMARKS in t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(if well field,one lathong is sufficient) 22.Certification:
34.55.679 N 80.34.707 W >
4-3-23
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or foNo with 15A NCAC 02C.0100 or 15A ArCAC 02C.0200 Well Constntclion Standards and that a
If this is a repair,fill out known well cotutruction information and explain the nature of the copy of this record has been provided to the well owner.
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 satne 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: 200 UQ 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple welly list all depths if different(example-3L200'atul 2(a)1003 construction to the following:
10.Static water level below top of casing: 23 (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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. 12oZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016