GW1--05818_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor information:
N 1
Frankie L.Oliver ;14-WATER ZONES .- . '
WellContracWrNarne FROM TO DESCRIPTION
87 ft. 172 ft.
3002-A 318 ft' 445 n' I
NC Well Contractor Certification Number 15 OUTER CASiNG(formulti-cased Wells)OR LINER(if ap licable): `V
Carolina Welt Drilling FROM TO DIAMETER THICKNESS MATERL%L
0 ft. 43 ft, 6 1/4 I hi' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)I `-
22-466
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. ;ill.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public ft U. in.
,Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft g in.
Industrial/Comsnercial Residential Water Supply(shared) 1$.GROUT
_ IIIl$ation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(16)501b Bags
_Monitoring
injection Well:
Recovery ft. ft.
ft. ft.
-:Aquifer Recharge Groundwater Remediafion 19:,SAND/GRAVF.LPACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier Stonnwater Drainage FROMTO
ft. ft.
MATERIAL EMPLACEMENT METHOD
Aquifer Test
Experimental Technology Subsidence Control ft. ft.
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Geothermal(Closed Loop) Tracer "20..DRILLING`LOG(attachadditioi allsheets if necessary) .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grains she,etc.)
]Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks)
0 ft' 15 ft' Brown Clay/Rock
4.Date Well(s)Completed: 8-14-23 )Well ID# 15 ft' 625 ft' Blue Slate
ft. ft.
5a.Well Location:
—
ft. ft.
Marco Rojas f-,«.-,A-...., r,,,{
Facility/Owner Name Facility ID#(if applicable) ft. ft. •1 r ‘C, L-.i V L d
2101 Mangum Dairy Rd.Monroe 28112 ft. ft. I' SEP 2023
ft. ft. l`
Physical Address,City,and Zip J
Union 04-060-001 B ,Z1,_REMARKS%J - . `, ,.. Inforira isf'?r,.-C ;'M l ll)i
Cu
County Parcel Identification No.(PIN) WOR2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: I
34.92.605 N 80.48.916 W
I. 8-23-23
6.Is(are)the well(s)MPernianent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify thatlthe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IN Yes or Eallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill Out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. i
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
9.Total well depth below land surface: 625 (it,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-4_4200'and 2(a3100') construction to the following:
10.Static water level below top of casing: 13 (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'forin within 30 days of completion of well
12.Well construction method: construction to the following: 1
(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(gym) 1 Method of test: Air 24c.For Water Supply&Injectio Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: -- 36oz completion of well construction to die icounty health department of the county
where constructed. I
Form GW-l North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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