GW1--07834_Well Construction - GW1_20231208

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14:,wATER ZONES _', ::f''.
FROM TO DESCRIPTION
Well Contractor Name
3002-A 119 ft- 280 fL
297 rt. fL
NC Well Contractor Certification Number
,15..OUTER CASING(for multi-cased'.wells)-OR LINER'(I applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL 107 fL 61/4 1t' SDR21 PVC
16.INNER CASING:OR'TIMING`( eothertiial closed:loop)
2.Well Construction Permit#: 23-228 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.'SCREEN :-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. iu.
Geothermal(Heating/Cooling Supply) j"QIResidential Water Supply(single) fL ft, in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20+ fL Bentonite Pour(36)50Ib Bags
Monitoring IlRecoveiy ft ft
Injection Well:
ft. rt.
Aquifer Recharge ID Groundwater Remediation jy SAND/GRAVEL PACE(if applicable)
Aquifer Storage and Recovery (Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage rt. rt.
Experimental Technology °Subsidence Control fL ft
Geothermal(Closed Loop) Tracer ,:20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
0 fL 8 f` Broviwn,Dirt
4.Date Well(s)Completed: 9-29-23 Well DM 8 f` 14 fL Red Clay
5a.Well Location: 14 fL 18 f` Brown Clay
Southern Interior Design Corp. 18 fL 39 ff Brown Rock
Facility/Owner Name FacilityID#(if applicable) 39 ft: 95 fL -L.¢. . ', y:••-
Y PP ) Gray Clay i a+ t -
Lanes Creek Township Farms Lot#6 Marshville 28103 95 fL 300 fL Blue Slate DEC 0
� r
Physical Address,City,and Zip IL rt. 1 rn;, -
�rl(
..
Union 03-114-002F 21.REMARKS •• . 1.
—•
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: i
34.48.592 N 80.23.586 W
10-10-23
6.Is(are)the well(s) Pernanent or Temporary Signature of Certified Well Contractor Date
By signing this,form, 1 hereby certjfy';that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: DYes or Eallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repute;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 fonn.
23.Site diagram or additional well details:
8.For GeoprobetDPT 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: 300 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths if different(example-3 00'and 2Q100') construction to the following: '
10.Static water level below top of casing: 24 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServicejCenter,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
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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: 18Oz 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 es Revised 2-22-2016