GW1--06687_Well Construction - GW1_20231024

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use}Only: ' i
1.Well Contractor Information: ' •
•Frankie L.Oliver ,,14.;WATERZONEs. y�jlm4,;: IV..-
Well Coritractar Name FROM TO 1 ' ' DESCRIPTION '
261 ft- ft. II
3002-A
!cf, 'ea i I
NC Well Contractor Certification Number 15:OUTER"CASING(for'itiulti-cased4ells),OR;LINER(Inap"lichble)
Carolina Well Drilling FROM '. TO ; ( DIAMETER . THICKNESS -- MATERIAL
Company Name , 0 It. 44 1 ft. 6 ii4 "In' SDR21 PVC '
CHA-WE-2022-00030 i'i NER'64,INCASINGORTUBING(geothernial'dosed•loop), ,:'' ,+. r: .
2.Well Construction Permit#:
FROM . TO •; ? DIAMETER • THICKNESS. MATERIAL
,Liu all applicable well cant:ructinu permits(i.e.IILC,County,State,Variance,etc.) H- I. Ft. I' ' dn.
I, .
3.Well Use(check well use):
It. 1 ft. II Yn •
Water Supply Well: i"17",SCREEN .-gl t ;:;f52,,..f.0!;§ :•t -r.., r<: , ,qr ,.!,,3
FROM TO. .. i I . DIAMETER. SLOT SIZE : THICKNESS . MATERIAL
'0Agricultural DMunicipal/Public ft. .f(: ?u.
DGeothetmal(Heating/Cooling Supply) 53Reaidential Water Supply(single) ft- ii, ' du. •
DIndustiial/Cominercial i DResidential Water Supply(shared) tK;GROUT I w
fItrigation FROM . TO ; f . MATERIAL ' 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ; 0 fa 20+' n' Berittoriite Pour(13)501b Bags
°Monitoring " . ; ORecovery 'et- 'Irt. ' ' I .
Infection Well:
.
I[jAquiferRecharge lGroundwaterRcmediation r.tp;SAN/GRAVELtP1CK(trsupliiiab k .. - ,3 t ..'0Aquifer Storage and Recovery °Salinity Barrier FROM TO + 9 ' `MATERIAL . ENIPLACEMENTMETHOD
AquiferTest
Experimental Technology
OStoima'aterDrainage It. i
Subsidence Control ft. 0
Geothermal(Closed Loop) • .QTracer `20 )ING'I OG?(attaeb additiotial:slieets if neeesshry); - �,? %' ,-
FROM TO ' DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) .Other(explain under#21 Remarks) ft.
0 . 16 . Red Clay. .
4.Date Well(s)Completed:'9-12-23 Well ID# 16 IL 26 ft' Brown Clav/Shale
5a.Well Location: 26 ft- 725 tt. Blue Slate
ft. ft. . . 1 . )i 'z ',1. • 1 1 1
Steven Thompson F. • .':T • ----, •
Facility/OwuerName Facility ID#(if applicable) rt. ft.
. . . �. 0(.1 ( «2023
7825 NO Hwy 200 Midland 28107
Physical Address,City,and Zip ft. rr. t rt,`or Tti,.^.i)i3c+. i•:'�':'=9(,'ill:'
i x tt YW tea. 5.+
Cabarrus N/A i"21';REVIARKS +`? € �S x ? .�(]t. k> . C..:M
'County Parcel Identification No.(PIN) . . I
-5b.Latitude and longitude in degrees/mintites/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
35.18.211 N 80.26.348 �t
. ,_� �Z 10-3-23
6.Is(are)the well(s)EaPetmmanent or Temporary Signature of Certified Well Contractor I Date
8y signing this form,7 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or igNo :with 15A NCAC 02C.0100 or 15A NCAC.02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction ii(lonnatian and etplairr the nature alike copy of this record has been provided to the well owner.
repair'tinder#21 remarks section or on the back of this form 2diagram 3.Site or,additronal 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 1 OW-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: 725 (11•) 24a. For All Wells: 'Submit this form within 30 days of completion of well
;For nudtiple wells list till depths it-different(e.rataple-3 tt 200'and 2©100) Construction to the following 1
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10.Static water level below top of casing: 1 a . (ft.) Division of Water Resources,Information Processing Unit,
:If water level is above casing,use"+" , 1617 Mail Service Center,Raleigh,NC 276 9 9-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection,Wells:•`In aiklition to sending the form to the address in 2Aa
Air Rotary above,also submit one copy oil this form within 30 days of completion of well
12.Well construction method: construction to the following: I 1
(i.e.auger,rotary,cable,directptish,etc.)
Division of Water Resourcch,;
Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servlc Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 112 Method of test: Air 24c.For Water Supply&Tnidctlon Wells: In addition to sending the form to
the address(es) above, also`submit one copy of this font within 30 days of
13b.Disinfection type: 70%HTH :Amount: .'44oZ . . completion of well iconstniction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division ofWater Resources Revised 2-22-2016
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