GW1--06796_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L. Oliver 14.WATER ZONES ':,
FROM TO DESCRIPTION
Well Contractor Name
47 ft- 58 ft-
3002-A
91 ft' 110 ft- I
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 43 rt. 6 1/4 ' In. SD R21 PVC
Company Name
23-205 16:INNER CASING OR TUBING`(geothermal closed-loop)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): • ft. ft. in.
17.SCREEN ..
Water Supply Well:
FROM TO DIAMETER SLOT SI'LE THICKNESS MATERIAL
Agricultural DMunicipal/Public • ft. ft. in.
Geothermal(Heating/Cooling Supply) 'In Residential Water Supply(single) it. it. in.
Industrial/Commercial DResidential Water Supply(shared) ltt.GROUT "
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft- Bentonite Pour(13)50Ib Bags
Monitoring DRecovety ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge i0Groundwater Remediation
IS.'SAND/GRAVEL.PACK(if applicable) c ,
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorniwater Drainage ft. ft. ,
Experimental Technology OSubsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additiaiialsbeets if necessary).:-; ,' -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 8 ft• Brown Clay/Rock
4.Date Well(s)Completed: 9-14-23 Well ID# 8 rL 200 ft- Blue Slate
5a.Well Location: ft rt. 4. .,,5 r 'l.� ,r;
r`i
ft. ft. • --„ e,.s, _,)
Southern Interior Design Corp. f 1
Facility/Owner Name Facility ID#(if applicable) it it. Q L L L123
2512 Ivy Run Dr. Indian Trail 28079 Angy Park#47 fL . ft tnf,-..;;l..-:;:.-� :.,,., ;_vr`�n r
Physical Address,City,and Zip Ft IL t—'`' 1'_`i] u
Union 07-015-058 21.REMARKS ..,-,
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: •
35.70.133 N 80.36.393 Wr
10-10-23
6.Is(are)the well(s)EaPennanent or OTemporary Signature of Certified Well Contractor; Date
By signing this font, 1 hereby cert(/ythat the well(s)was(were)constructed in accordance
. 7.Is this a repair to an existing well: JjYes or MINo with I5ANCAC 02C.0100 or 15ANCAC 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:
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 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: 125 (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 2Q100') construction to the following:
10.Static water level below'top of casing: 10 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServiceiCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (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) 30 Method of test: Air 24c.For Water Supply &Injection Wells: In addition to sending the form to
the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 120Z 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 Resour les Revised 2-22-2016