GW1--07836_Well Construction - GW1_20231208

i !
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1
Frankie L. Oliver 14:-WATER ZONES'
'"
FROM TO DESCRIPTION
Well Contractor Name 84 ft' 90 ft' I f
3002-A 112 ft' 148 ft'
NC Well Contractor Certification Number 15.OUTER CASING(for iuulti•casedwells)OR LINER(if applicable)_
CarolinaWell Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 56 ft- 6 1/4 ' in' SDR21 PVC
Company Name
'16;INNER CASINGOR TUBING°(geothermal closed•loop)-- ` ,
2.Well Construction Permit#: 21-195 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.INC,County,Stare,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DIMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply') MI Residential Water Supply(single) fy ft. in.
Industrial/Commercial IResidential Water Supply(shared) 18 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft- Bentonite Pour(16)50Ib Bags
Monitoring fRecovety ft. ft. 1. , ,
Injection Well:
ft. ft.
Aquifer Recharge :1Groundwater Remediation I
19.SAND/GRAVEL°PACK(if applicable) ` " `
Aquifer Storage and Recovery Et Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stomrwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft- ft.
Geothermal(Closed Loop) DTracer '20..DRILLING LOG(attach additional sheets if necessary) ,'---
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft- 12 ft- Brown Clay/Rock
4.Date Well(s)Completed: 9-28-23 Well ID#i 12 ft' 200 ft' Blue Slate
5a.Well Location: ft. ft. t 't 4.,„.,„d &.., 3
Zeke Gray ft ft. DEC a
Facility/Owner Name Facility ID#(if applicable) ft. ft. ` L 3
4743 Dusty Ln.Marshville 28103 ft ft. tit'`;'" ':7n `'�-' -• ur
''' g rrf
Physical Address,City,and Zip
Union 01-120-015A 21.REMARKS
I
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:
35.60.566 N 80.22.104 W
10-10-23
6.Is(are)the well(s)0Perrnanent or OTemporary Signature of Certified Well Contractor, Date
By signing this,form. 1 hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 111 Yes or j!j'No with 15ANCAC 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:
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
depth below land surface: 200
9.Total well (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 2®100) construction to the following:
i
10.Static water level below top of casing: 33 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,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) 13 Method of test: Air 24c.For Water Supply&Iniection 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: 120Z completion of well construction)to the county health department of the county
where constructed.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016