GW1--05815_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 I
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Frankie L.Oliver .14:WATER ZONES -- : l-
Well ContractorNaine FROM TO DESCRIPTION
3002-A 47,52 ft. 61,65 ft. I
86,111t• 127 ft' 185 1
NC Well Contractor Certification Number
'IS.OUTER'CASING,(for mutU=casedwe113)OR LINER(if ap livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 43 ft' 61/41 in' SDR21 PVC
Company Name 16.INNER CASING OR TUIRING;(geothermal closed-loop) ' -"
2.Well Construction Permit#: 23-200 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. , ht.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.. ':., , '
FROM TO DIAMETER ' SLOT SIZE THICKNESS _ MATERIAL
Agricultural OMunicipal/Public ft, ft. in.
Geothemial(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.'
hrdustrial/Cornrnercial OResidential Water Supply(shared) IR.GROUT tI
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Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
• Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(27)501b Bags
_ Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
'19.SAND/GRAVFT;PACK(If applicable) + . • '
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage
ft. ft.
Experimental Technology OSubsidence Control ft. ft. 1
Geothermal(Closed Loop) I Tracer 20.1DRILLING'LOG!(attach additional sheets if necessary):`-- , "-
FROM TO DESCRIPTION(color,hardness,sailhock type,grain size,etc.)_
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft* 3 ft' White Sand
4.Date Well(s)Completed: 7-24"23 Well ID# 3 ft' 11 ft• Red Clay --
5a.Well Location: 11 ft* ft• Granite Rrtac.i a
Jacquelyn McNeely ft. ft.ft. ft. SEP 2023
Facility/Owner Name Facility ID#(if applicable)
1805 Starnes Cemetery Rd. Monroe 28112 ft. ft. lr.f^rN,2:icft Pr,,.c; ,.;"„3 Ur$
Physical Address,City,and Zip ft. ft. OW UPI:
Union 04-237-026B z1.REMARKS=, F
County Parcel Identification Nu.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
34.50.488 N 80.34.573 W
7-26-23
6.Is(are)the well(s)MPermanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify than the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or reNo with!SA NCAC 02C.0100 or 15A NCACI02C.0200 Well Construction Standards and that a
If this is a repair,fill out Noma well Coeceructian information and explain the nature of the copy of this record has been provided to the well owner.
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repair under#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 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.
drilled: '
SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: 200 tit.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2L100') 1
construction to the following:
10.Static water level below top of casing: 16 (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 Ifonn within 30 days of completion of well
12.Well construction method: construction to the following: t
(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) i0 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 i eI county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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