GW1--00926_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ,
is
Frankie L. Oliver
Well Contractor Name FROM TO DESCRIPTION
3002-A 82 ft. 143 ft'
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for m uln.cos'edhwelLs)OR LINER(if applicable)
Carolina Well Drilling _FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft, 50 ft. 6 1/4 I in. SDR21 PVC
16.INNER CASING OR TUBING-(geothermal closed-loop) _"
2.Well Construction Permit#: N/A 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): ft ft in
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMuuicipal/Public ft. ft. in.
0Geothermal(Heating/Cooling Supply) MEiResidentia1 Water Supply(single) ft- n. in. ,
DIndustrial/Commercial DResidential Water Supply(shared) ,"'1R GROUT. "
IlIrtigation FROM TO MATERIAL :EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ fc. Bentonite Pour(13)50Ib Bags
DMonitoring DRecovery ft. ft.
Injection Well: ft. et
DAquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery ['Salinity Barrier FROMND/GRTOEL'PACR.(iM MATERIAL EMPLACEMENT METHOD {„.
Aquifer Test
Experimental Drainage f[ rt.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer '20."DRILLING LOG(attach additional sheets'if necessary) ._
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,etc.)
0 ft 6 ft. Orange/Brown Sandclay
4.Date Well(s)Completed: 12-14-23 Well ID# 6 ft- 15 ft' Brown Sandclay
5a.Well Location: 15 ft 25 et. Brown Clay
Vanessa Tran Well#1 25 et ft 40 Grey Clay ;a1_..0 '1.j t7 j\ ^kJ
Facility/Owner Name Facility lD#(if applicable) 40 ft- 400 it. Granite EU 2024
Teal Hall Rd.Morven 28119 ft. ft.
Physical Address,City,and Zip fL ft fir. lent Prl^lcagoiti;g URIC!
Anson N/A -'2i.REMARKS.r7, .' 1 ' . ,.�a`,"# '''ti
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: ,
34.52.577 N 80.40.616 �, '
i 12-15-23
6.Is(are)the well(s)0Perrnanent or )Temporary Signature of Certified Well Contractor Date
!J By signing this,form, 1 hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or j di No with ISA NCAC 02C.0100 or 15A1VCAC 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/l21 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: 400 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100) construction to the tollowing:
i
10.Static water level below top of casing: 18 (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
(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
I
13a.Yield(gpm) 8 Method of test: Air 24c.For Water Supply & Injection Wells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 24oz 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