GW1--06783_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
•
Frankie L.Oliver :14.1WATER ZONES ,.:; ?:,
Well Contractor Name FROM TO DESCRIPTION
3002-A 72 ft- 292 R
• 425 f t. 528 ft*
NC Well Contractor Certification Number F;15.tiOUTER•CASING(far inulti casedi.ivells)OR LINER-(if ap illcable)
Carolina Well Drilling FROM ' 'TO ' ' DIAMETER THICKNESS MATERIAL
Company Name 1 PVC
0 ft' 45 fL 6 ./4 In' SDR21
'22-360 i 16::INNER CASING OR TUBING,(geothermal`closed-loop)r 's, r`� .": '', ",."'
2.Well Construction Permit#: t ' FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ire.UIC,County,State,Variance,etc.) ft, ft. i hi.
3.Well Use(check well use): fa ft. I in.
Water Supply Well: '17:SCREEN ,0... .,, ., -i '- -`? ':.., .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i OMunicipal/Public ft. ft. I in.
Geothermal(Heating/Cooling Supply) j 4 Residential Water Supply(single) ft. ft. I in.
IndustrialConnnercial 1 DResidential Water Supply(shared) ,
Gc t
Irrigation j FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ ft, Beltonite Pour(14)50Ib Bags
Monitoring ; DRecovety ft. ft. 'i ' '
Injection Well: •
ft. 1't.
Aquifer Recharge i iGroundwater Remediation
19.S;t.ND/GRAVEL'PACK((raplslicable) .,:::r. .', 'A:+40 ''.':.`.,.
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage fa rt. '
Experimental Technology OSubsidence Control fL ft.
Geothermal(Closed Loop) DTracer • .•20:DRILLING LOG'(attach'additional sheets if necessary) : .. '.,..�
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,lwnlness,solUrocktype,grain size etc.)
0 ft. 12 ft- Red/Brown Clay
4.Date Well(s)Completed: 10-2-2$ Well LD# 12 it 600 ft. Blue Slate .
5a.Well Location: , •
ft. ft. . _b `
r,,N..._.is V. l.a, I
Cody Munn . . /
Facility/Owner Name Facility ID(f(if applicable) ft. ft 0l, I /. 2073
7247 Sugar&Wine Rd.Monroe 28110 ft. rt. •
fi' ,^
Physical Address,City,and Zip • O- frt. ^ ,C,�+ice.. 12(' IJ .
Union
01-195-009 ,2i.REMARttS'S, ,.. t , . .a , "; " t. 3-6\:
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .22.Certification:
35.13.925 N 80.39.591 W
f ( �.:- 10-1 0-23
' 6.Is(are)the well(s) Permanent or Temporary iguature of Certified Well Cantrpctar Date
I
By signing this,fomi, 7 hereby certjfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: LiYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cons:,action Standards and that a
lfthis is 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 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 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: 600 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 it 200'and 2©100') construction to the following: ''
10.Static water level below top o casing: 21 (ft_) Division of Water Reso furces,Information Processing Unit,
If Water level is above casing.Use"+' ; 1617 Mail Servicel`Center,Ralelgh,NC 27699-1617
11.Borehole diameter: 6 (In.) 24b.For Infection Wells:i In addition to sending the form to the address in 24a
Air Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: '
(i.e.auger,rotary,cable,direct push,etc.) I j
Division of Water Resources`,Underground Injection Control Program,
FOR WATER SUPPLY WELLS1ONLY: 1636 Mail Service!Center,Raleigh,NC 27699-1636
i
13a._Yield(gpm) 3 Method of test: ,Air 24c.For Water Sunalv.&Tnjection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70° HTH Amount: 36oz completion of well construction to the county health department of the county
where constructed. I
i 11
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Itesou les Revised 2-22-2016