GW1--05819_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i• 1
1.Well Contractor information: •
I I I
Frankie L.Oliver .14:%VATER=ZONES, . ,1 ':13'.y3 G:,' ",,
FROM TO t t t DESCRIPTION1
Well Contractor Name 160 rf 265 ft. ; I i
3002-A ,
ft. Ift
• . 1 F
NC Well Contractor Certification Number 15 7.OttTRR CASiNG`(far inult(-cased veils)OR'I.iNER:(if'ap licable)' r. ,
Carolina Well Drilling FROM TO , :I DIAMETER- !I THICKNESS " MATERIAL '
Corn an Name 0 ft• 45 ' jft• b i 'in SDR21 PVC
P Y 22-461 o I6.iNNERICANINF OR TUBING(geutlierinal closed-loop)',:t -
2.Well Construction Permit#: ' FROM TO : t I DIAMETER THICKNESS MATERIAL ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ! I !in.
. 3.Well Use(check well use): ft, ' 1ft. I in.
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;,,17.SCREEN s.,i`- y.y ,• ;.,) 's T3{. ..:t .. .,"c
Water Supply Well: FROM TO i DIAMETER SLOT THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. - tt.! I ! In.
( .
EDGeothemlal(Heating/Cooling Supply) OResidential Water Supply(single) ft. t',l I ,'id, t
ID Residential Water Supply(shared) IR.'GROUT :. "i'"i'',' <,` .
flirrigation FROM' ! TOy ; ;�t ' 'r MATERIAL EMI'LACEMENTMETHOD-&AMOUNT
';
Non-Water Supply Well: , 0 _ rt• . 20+1 n• Be'ntpnite Pour(12)501b Bags
Monitoring DRecovery ft. ' i ft. I I '
injection Well: • ft. ft. I i
0Aquifer Recharge 0Groundwater Remediution '
!-19.SAND/GRAVF.1rl!ACK fir applicable) " ' .,
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM To' .I MATERIAL EMPLAI.EMENTMETIHID
0 Aquifer Test 0 Stonnwater Drainage ft. i ft. ! ' I
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ;110::DRILL1NG IiOG.(attach addittinial sheets ifnecesaaty) '''`
FROM TO' ' !' DFSCRTPTTON(color,hardness,soihlrock type,grain slit,eta)
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) i
0 it. 25 ff brown''Clay/Rock ,
8-15-23
4.Date Well(s)Completed: Well ID# 25 ft' 500: ft' !Slue Blue Slate
ft. i ft.
5a.Well Location: I i� "'' 3"-' j�'-: ,i
Tanner McMahan ft. n. I t g..i Li.
Facility/Owner Name Facility IDII(if applicable) ft. i ft. I 023
1411 Brice Griffin Rd.Marshville 28103 ft. , ft.
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Physical Address,City,and Zip ft. ft. nfr, Tr,t r. 'i Palcntv..41y;?,sg(.:R i
?t21:.REMARBS:,':iu =ai 1 t . `.*.pPf.1:N-:.f�1.h:,i..,"'. ,»;,;i
Union 02-077-011 D01 ,
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County Parcel Identification Nu.(PIN) •
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5b.Latitude and longitude In degrecshninutes/seconds or decimal degrees: 1
(if well field,onelatllong is sufficient) 22.Certification:
35.02.105 N 80.33.756 Vy p� i 8-23-23
6.Is(are)the well(s)DoPernlauent or OTentporary Signature of Certified Well Coutr ictor • Date
,By signing this form,1 hereby,cern} that the well(s)was(were)constructed in accordance_
7.Is this a repair to an existing well: DYes or EjNo with 15A NCAC 02C A100 or'l5A 1''CAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out hwwn well construction irl/brntation and explain she 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. •
'23.Site diagram or additional iwell 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 I
9.Total well depth below land surface: 500 • tit,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erimrple-3@2(10'and 2(a31O0') construction to thaollowipg:
i
10.Static water level below top of casing: 19 (ft.) Division;of Water Resources,Information Processing Unit,
.If nester level is above casing,use"+" 1617 Mail Service i esiter,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter: - ,6 . (in.) 246.For Iuiection Wells 1 In addition to sending the form to the address hi 24a
Air Rotary above, also submit one copy f this-form within 30 days of completion of well
12.Well construction method: construction td thetfollowing: I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resour es,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 4636 Mail Service Center,Raleigh,NC 276 9 9-1 63 6
13a.Yield(gpm) 1 Method of test: Air 24c.For Water,Supply&Iniection Wells: In addition to sending the form to
' the addresses)above,-also's biriit lone'copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 30oz completion of Well conshuetibn to the county health department of the county
. where constructed. I
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Form GW-I North Carolina Department of Environmental Quality-DivisionkofWaterRes urces Revised 2-22-2016