GW1--00958_Well Construction - GW1_20240208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: II
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1,Well Contractor Information: r ;I
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Frankle L.Oliver I §f4:R'ATSR=20NE5 Wo:.';;e ..,m..,, r' ,,iTf 5, ,. . , .
Well Contractor Name i FROM TO I DESCRIPTION •
3002-A 106 ft. 250 ,ft. 1
620 ft. 645 ft'
NC Well Contractor Certification Number -
ii5:;Oi1TER'CitiS11VG:(for inultt casedt,ivells)!OR LINER Kati lleable)
Carolina Well Drilling FROM TO " DIAMETER • THICKNESS MATERIAL
0 ft. 43 fa 61/4 In, SDR21 PVC
Company Name +461NNER CASIN(U OR'TUBING'(geathernial'cliked;loop)" S ,; ,t. ..rttMir t f i.s
2.Well Construction Permit#: 23-290i FROM TO ' I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.'UIC,County,State,Valance,etc.) ft. ft. i In.
3.Well Use(check well use): fa ft. e•
in
Water Supply Well: FROM BEEN TO
» DIAMETER .f SLOT SIZE THICKNESS MATERIAL {
Agricttltural DMunicipal/Publio ft. ft. Iti.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. 1ti
Industrial/Commercial OResidential Water Supply(shared) 1tt:;GROUT ' 1, °:�; 3 r': '.;' ..
Irrigation FROM TO MATEiUAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f 0 ft. 20+ fL Bentonite Pour(17)50Ib Bags
Monitoring Recovery ft. i ft. 1; '
Injection Well: ! ft. ft. f
Aquifer Recharge •i 0Groundwater Remed iation ,,.}
i 19;=$AND/GRAVEL PACK:(ir applteiible)
Aquifer Storage and Recovery ( ©ISalinity Barrier FROM ' ` TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 1 DStormwater Drainage ft. ft. !'
Experimental Technology 1 E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer `20;D1t1I:LINGI OG?(attilthittldltitiital:sheets if neCeesaey) Cs�.< , x v:°aim ..3 :
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft TO ft. DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
i 0 15Red Clay
4.Date Well(s)Completed: 12-6-23 :Well ID#i 15 R. 24 Brown Shale
5a.Well Location: 24 ft• 650 it Blue;Slate
ft. rt. i l "—
Jennifer Shearer N�.C E ry
Facility/Owner Name Facility ID#(if applicable) ft- It. 1 L.L.)
910 Jug Broome Rd. MoNQoe 2.8f2. ft FEB 8 2024
Physical Address,City,and Zip
Union 04-096-001 C a.2
ft. ft, inkrft'131..IE"1,'►r,..4 Zt.
l REMARKS $;-.I :r` nz ;�IarL; " 7.,Y.`. :`i,t „4..s t3tAki- ,.Y.Urta,.la:
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '
34.52.374 N • .80.30.268 W 12-11-23
6.Is(are)the welks) Permalient ,or EDTemporary
Signature of Certified Well Contractor, Date
8y signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or No with 15A NCAC 02C.0100 or 15AANCAC 02C.0200 Well Construction Standards and tiwt a
If this is a repair,fill out blown well constrlctiou information and esplain 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: , 650 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For midhiple wells-li.st all depths if different(crumple-3@200'and 2Q100') construction to the following: j
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Division of Water Res 10.Static water level below top or casing: 15 (i t) ources,Information Processing Unit,
if water level is above casing,use"+" i 1617 Mail Service!Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6; • (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I Air Rotary above, also submit one copy;of this form within 30 days of completion of well
12.Well construction method: I construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS QNLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 25 II Method of test: Air 24e.For Water Supply&iniectiou Wells: in addition to sending the form.to
I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTl Amount:`, 3804 completion of;well construction'to the county health department of the county
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where constructed. i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resoures Revised 2-22-2016