GW1--06688_Well Construction - GW1_20231024

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 5:14 WATEIt•ZONES „;:.zs lY"t,::`1. *.;"s ;'.•M i'I ..
Well Contractor Name , FROM TO -t DESCRIPTION
3002-A 105 ft 124 ft. !1 '
137 ft 197 : ft, :1
'NC Well Contractor Certification Number :IS.'OUTER-CASING(for inutti-rased wells);OR LINER'(tf`ap livable) 4 , .
Carolina Well Drilling FROM TO •1 DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 87 ft. 6 1/4: in' SDR21 PVC
CHA-WE-2023-00033 '16 INNER;CASINGOR=TUBING(geiitherfiialdosedaoop)-. .-s , ,:;•t' , -,
2.Well Construction Permit#: FROM TO. t_ DIAMETER THICKNESS MATERIAL
Lira all applicable well construction permits(i.e.U/C,County,State:Variance,etc.) ft ' ft. i in.
3.Well Use(check well use): It. ' ft. In.
. e 17.SCREEN 4,1., Y, ,-, ': t•`: � ;
Water5n 1 Well: ,.t'
Supply FROM TO ' DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public it ft. ,in.
Geothermal(Heating/Cooling Supply) oRecidential Water Supply(single) ft ft. . fin
Industrial/Commercial DIResidential Water Supply(shared)
. . . ;, ...mot ... , .
Irrigation FROM ' TO MATERIAL EMPLACEMENT METHOD a AMOUNT
Non-Water Supply Well: 0 ft' 20 # fL Bentonite Pour(22)50Ib Bags
Monitoring ' IDRecoveiy ft. ' ft. 1
i
Injection Well: rt f rt.
l;
Aquifer Recharge (°Groundwater Rcmediation
'19:SAND/GRAVELtPACKor applicable) _ ` .
.Aquifer Storage and Recovery QISalinity Barrier FROM TO . 'MATERIAL EMPLACEMENT METHOD
Aquifer Test DStotmwater Drainage ft. ' It.
Experimental Technology E3Subsidence Control ft. it.
Geothermal(Closed Loop) ;Tracer =2o:DItILLING;LOG(attach'additional"sbeetsifnecessary) . : 't=4, .`'` f
Geothemial(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO
TO DESCRIPTION(color,hardness,sail/ruck type,Rratn slzc,etc
.)
0 67 Brown Clay
4.Date Well(s)Completed: 8-24-23 . Well ID# 67 rt 75 ft Brown Shale
5a.Well Location: 75 ft 200 CL Granit L..( 'r, A v f;..+i`4
S
Daniel&Vivian Robbins Cl
Facility/Owner Name Facility IDN(if applicable) it ft U 1 I' 2023
315 Pinewood Ln.Midland 28107 ft. ft F
:Ira, ,. ;"' ia--` '
ft ft. t/Y b�,1 2.1 1G J L i l
Physical Address,City,and,Zip
Cabarrus N/A . .,;2I`REMARKS+••,a,s., Sri Ts . ,Y.. - .,. 'r Fr;; 0;' '� ...,.k'.�o ,}
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.23.110 - N '80.57.390 . W 9-23-23
Perrnanent or Tern ora ignature of Certified Well Contractor Date
6.Is(are)the well(') P ry
By signing Ibis form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to sin existing well: JJYes or Isallo with 15A NC4C 02C.0100 or 15ANCAC 02C.0200 We!!Construction Standards and that a
If this is a repair,jilt out k notirn well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks seition,or on the back of this.fonn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d{8erent(eraunple-3@200'and 2Q1110') construction to the following: j
10.Static water level below top of casing: 42 (ft.) Division of Water Reources,Information Processing Unit,
If water level is above casing,use"+" 1 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (In.) 24b.For Infection Wells: Ie?ailditiun to sending the form to the address in 24a
Air Rotary above, also subunit one copy ofjthis form within 30 days of completion of well
12.Well construction method: construction to the following: ! I
(i.e.auger,rotary,cable,direct push,etc.) I t 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) 22 un
Method of test: Air 24c.For Water Simply&injection Wells: in addition to sending the form to
the address(es) drove, also shbmit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 12o2 completion,of well construct p i to the 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