GW1--05825_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver -14:WATER-ZONES - ,: {- ' -.
Well Contractor Name
FROM TO DESCRIPTION
3002-A 49,51 ft' 64,69 ft' I
73,78ft' 85,92 ft. 99103,h112,119122,126,156,169,194
NC Well Contractor Certification Number 15.'OUTER'CASING(for multt•cased Wells)OR!!NF.R'(if ap licable),`
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
0 ft. 43 ft' 61/4'' t°' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)` . °
23-154
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. 1 In.
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL.
Agricultural DMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) 5aResidential Water Supply(single) it. it, in.
Industrial/Commercial OResidential Water Supply(shared) 98.GROUT r r
P - ;7� . � ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rut. 20+ ft' Bentonite Pour(19)50Ib Bags
Monitoring ORecovery fL ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRA3 EL:-SACK(if applicable)
Aquifer Storage and Recovery OSaliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EnStormwaterDrainage ft. ft.
Experimental Technology EDSubsidence Control ft. ft. ,
Geothermal(Closed Loop) EpTracer 20.DRILLING LOG(attach additional sheets if necessary,) •`- . `.
FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under 421 Remarks)
0 ft' 10 ft' Red Clay
4.Date Well(s)Completed: 6-1-23 Well ID# 10 ft. 23 ft' Brown'Dirt
5a.Well Location: 23 ft' 31 ft. p e '
ft. ft. Brown Rock V Le 1'd ' "-
James Tant 31 200 Granite '
Facility/Owner Name Facility ID#(if applicable) ft. ft. S EP 0 1 2023
1705 McIntyre Rd.Wingate 28174 ft. ft. 7r Ri l'rf
ft. ft. tT1i- 'v.m2�-�:,:.,�,Pxe•
Physical Address,City,and Zip Gtr�A,4�
Union 09-009-002
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
35.10.116 80.26.487 4-=_
6-28-23
6.Is(are)the wll(s) Permanent or Temporary Signature of C ed Well Contractor Date
By signing this form,I hereby certify Mai the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: II Yes or ONo with 15A NCAC 02C.0100 or 1SA NCAC;02C.0200 Well Constnlction Standards and that a
if this is a repair,fill ma krviun well crmsmtction information and eaplann 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.
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.
i
drilled: SUBMITTAL INSTRUCTIONS j '
I' .
9.Total well depth below land surface: 200 (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(a)200'and 2@100') construction to the following: I
10.Static water level below top of casing: 26 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 i i
11.Borehole diameter: (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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ 38 Method of test: Air 24c.For Water Supply&Injection I Wells: In addition to sending the form to
the address(es) above, also submit lone 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. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016