GW1--04449_Well Construction - GW1_20230710

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WELL CONSTRUCTION RECORD (GW-1) For Internal;Ur;e Only: I
1.Well Contractor information:
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Frankie L.Oliver >14::WATEwzONES fK' ...-;.-,',1-
Well Contractor Name
FROM TO'' DES�RWTION
3002-A 138 fL 176, it. i •
271 ft. 285.. ft' I 1
NC Well Contractor Certification Number !',15:.OUTER'CASiNG'(for tnuld?lased-wells)OR:1JNRR•(Irap'lleablol: ',:
Carolina Well Drilling FROM TO!'; •DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 113 ft. 611/4 in. SC�R21 PVC
23-98 ':16:INNER CASING:OR TUBING+(geothermal'closed=lao]i)'t :.,,,
2.Well Construction Permit ft: FROM TO ` . DIAMETER THICKNESS MATERIAL
List all applicable well construction petmits(i.e.U1C,County,State,Variance,etc.) ft- ft. In.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: .'I7,•SCREEN ; _= 1 l-',;,;2, ...-,,
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERiAi
3Agricultural OMunicipal/Public r(. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. • B- '( in.
3Industrial/Cominercial E3Residential Water Supply(shared) '.1S.GROUT Ii f .Is ,.
',Irrigation FROM TO-', .,MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ il' Be itonite Po it(32)501b Bags
3Monitoring °Recovery ft. ' ' ft. 1
injection Well:
ft. It. I
Aquifer Recharge ®Groundwater Rernediation
t,19.:SAND/GRAVEL,PACK,(if,ap'pfcnhle) ,r:. . .'.f' :a
°Aquifer Storage and Recovery •®Salinity Barrier FROM To I I: MATERIAL EMPLACEMENT METHOD
EDAquifer Test 0Stnrmwater Drainage ft. ft. If
JExperimental Technology 0Subsidence Control ft. ft.
RGeothermal(Closed
Loop) 0Tracer i20.-11RILLING i OG(altitch idditiondISIteets•ifneeessary); ,: i" v. ; ;;•;
FROM TO: DESCRIPTION tcolor,hardness,soil/rock One,grain slue,etc.)
Geothermal(Heating/Cooling Return) flOther(explain under 4121 Remarks)
0 ft, 4 ft' Yellow Clay 1
4.Date Well(s)Completed: 5-19-23 .Well ID# 4 rt. 27 ft' Rid Clay i _
5a.Weil Location: 27 et. 81 rt. Brown Sandclyl rt q't� • k "k;i`ii""li�,`
Pedro Rojas 81 f' 300 rt' Blie Slate 1 • ' (�
Facility/Owner Name Facility IN,(if applicable) It. ft. I I J lJ 1 �`��
6221 Philadelphia Church Rd.Marshville 28103 ft. ft. I r ,,� ,•��_� _ l,n:
Physical Address,City,and Zip I CV°"`
inOG
Union 03-111-009D 21:REM IRKS;r;' . ,. , ,._ 1 4„,.. i. <, ,,>,
County Parcel Identification No.(PIN) I
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: j
(if well field,one ladlong is sufficient) 22.Certification: i
34,50.104 N 80.23.309 W
'��•IT ��� 6-16-23
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified W aoE racTr Date
By signing this form,I hereby certfly that the well(s)w (were)constructed in accordance
7.Is this a repair to an existing well: IjYes or 15allo with 15A NCAC 02C.0100 or 15A{t'CAC 02C.0200 W li Construction Standards and that a
If this is a repair,fill out bunt•n well construction it fi,rmation and explain the nature of the cop)of This record has been prnvid to the well owner.
repair cinder#21 remarks section or on the back of this form. J
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 age to provide atditiunal well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may !so attach addition al pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'ruin I W00) construction to the following:
10.Static water level below tap of casing: 27 (ft.) Division of Water Resources,Infornust1on Processing Unit,
If water level is above casing,use"+" 1617 Mall Servi a Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inlecdolt Wells: In ddition to seudin the form to the address in 24a
Air Rotary above, also submit one copy this form withi 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) 14 Method of test: Air 24c.For Water Supply&In ection Wells: In addition to sending the form to
the address(es) above, also submit one copy .f this form within 30 days of
13b.Disinfection type: 70%HTH Amount: l8OZ completion of,well constructs to the county ealth department of the county
- where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Reco rees Revised 2-22-2016
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