GW1--06795_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD (GW-1) _For Internal Use Only:
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1.Well Contractor Information:
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Frankie L.Oliver . 14.WATER zONES; `
FROM TO DESCRIPTION
Well Contractor Name -
45 ft- 81 ec
3002-A
95 ft- 108 ft- 170,183
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 fL 43 ft. 6 1%4 . in' SDR21 PVC
Company Name
16.INNER CASING'`OR TUBING closed-loop) ......`` '
2.Well Construction Permit#: 23-206 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft in
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
11 Agricultural DMunicipal/Public ft. ft. in.
in Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. It. in.
IN Industrial/Commercial DIResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft- Bentonite Pour(14)501b Bags
;)lIl Monitoring IDIRecoveiy ft. ft.
Injection Well: '
ft. rt.
Aquifer Recharge 0 Grou ndwater Remetliation 19.SAND/GRAVEL.PACK(if applicable)
MI Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1'Aquifer Test DIStmmwater Drainage ft, ft.
0 Experimental Technology 0Subsidence Control ft. ft.
*Geothermal(Closed Loop) OITracer 20 DRILLING.LOG(attach additional sheets if necessary) r. •.
a Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(caluq hardness,suil/rvck type,grain size,etc.)
0 ft- 6 ft. Brown Clay/Rock
9-13-23 rut rut �y
4.Date Well(s)Completed: Well ID# 6 200 Blue Slate r-
5a.Well Location: rt. l --"A.. -1: 'd y '.a_^ r
Southern Interior Design Corp. ft. ft. OC T,1 ��
Facility/Owner Name Facility ID#(if applicable) ft. ft. -d '- 2023
2508 Ivy Run Dr, Indian Trail 28079 Angy Park#46 ft et. n ''^ ,-
Physical Address,City,and Zip
rt. ft
2ls'REMARKS
Union 07-015-057
County Parcel Identification No.(PIN) I,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification: I
35.70.179 N 80.36.375 `,(,
10-10-23
6-Is(are)the well(s)EiPerinanent or [Temporary Signature of Certified Well Contractor, Date
By signing this,form, 1 hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 1l Yes or No 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 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:
S.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 GW-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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 1QI00') construction to the following:
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10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail ServiceiCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServiceiCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply&Injection 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: 12oz completion of well construction 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