HomeMy WebLinkAboutGW1--00959_Well Construction - GW1_20240208 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: , i
1.Well Contractor Information:
Frankie L.Oliver ! t 14.,W-9TER;:zON `r +art., hr.n �.3,, ,a, t v, ,;ft,��r Kp ,.,a
FROM TO ' DESCRIPTION
Well Contractor Name 230 ft. 270' fL 1 1
3002-A
•
371 ft. et.
'NC Well Contractor Certification Number
I1415401ITEWCASiINGOinintilri easeH wells)4OR LINER:(Ifi R ll able) 44 r, . :, ,
Carollna Well Drilling i FROM - TO ' • DIAMETER' THICKNESS MATERiAL
Company Name 0 ft- 65. ' ft. 6 u A In' SDR21 PVC
'23-298 ;K,ls`:1NNERiCASING'OR TUIflNGYge ltliefinialxlosed.looiil'> ,s,. :;,.•,." ?, ., , F
2,Well Construction Permit#: • 't FROM TO DIAMETER • THICKNESS MATERIAL
,Lis/all applicable well cotulruclion perntite(i.'.I/IC,County,"State,Variance,etc.) ft. ft. i 1. in:
:3.Well Use(check well use): i ft ft. ,'in
vk l7ISCREENii ^ 0c.. ?;.Y: /I P iii ,.'�1;1: �°`NI I ,t W rItit ttlIM t tV-.'i
Water Supply Well.: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural j, [DMunicipal/Pub]ic .ft. '-ft, 14
II Geothermal(Heating/Cooling Supply)
111 faResidential Water Supply(single) • ft- i ft. kin
IIII Industrial/Commercial I
i Residential W ter Supply(shared) uk RIROUT.. .zl x,E a # , 1.w, v ,1� Ali ;;
*Fp. " yt`aZ ,,
Irrigation . . i FROM TO ! ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: i 0 :ft- 20+ EL Beritonite ' Pour(.16)50Ib Bags
Monitoring ; E3Recovety fL : ft.
•
• Injection Well: ft. • ft.
II Aquifer Recharge 1 It Groundwater'Remediation
i 9.'SAND/GRAVECf PACK(q&ilical le) 214' Z4liti"r41s 4kۥTAWI r R.R:`1
Illri Aquifer Storage and Recovery j EtSalinity Barrier FROM TO ' MATERIAL EMPLACEMENT METHOD
'I'Aquifer Test ; DStorritwater Drainage Ft. ft.
II Experimental Technology ; OSubsidence Control rt. ' It.
r
II Geothermal(Closed Loop) QTracer k4.`20:L1lILIANGrtOG:(atineh?7tdditititiiilsheetit if'iiecesstury�)"�vx;,g'x;:n:?. "ii , ,, L:
FROM TO DESCRIPTION(color,hardness,sou/ruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 f e 46 ft- Brown'Clay/Shale
4.Date Well(s)Completed: 1-3-24 'Well ID# 46 fL 400 ft. Blue Slate
Sa.Well Location: r' '
rt. 'rt. F� a "u roR :'
James Roberts ' ¢ E g q
Facility/Owner Name Facility ID#(if applicable) IL _ rt. b..,t
412 Sara Ln. 'Monroe 28112
ft. ft. F t 8 2024
Physical Address,City,and Zip ft. It. ItIt rite-,,e+.i r7 e.
•
'2,artEAlARKs'„, .1�;;+;.`1,1,.. ,v�132i?-arks.c;` -0.4,,4 .d:(+ itN 3 F�•.
Union 04-168-007A ,
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,onelatllong is sufficient) 22.Certification'
34.92.553 N 80.55.549 w c/- '' �` ' 1-9-24
Signature of Certified Well ContractorDate
6.Is(arej the wel(s)i`!Permanent or DTemporary' I
By signing this,form, 1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYts or .<No
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stundar4t and that a
If this is a repair,fill out bwwn well construction information and eiplain the nature of the copy of this record has been provided to the bell owner.
repair under4121 remarks section or on the back of this form
23.Site diagram or additional well;details:
8.For Geoprtibe/DPT or Closed-Loop Geothermal Wells having the same 'You may rise 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 went list all depthr if different(example-3 ,200'and 2@100') construction to the following: I
10.Static water level below top of caging: 22 (ft) Division of Water Res' rces,Inforn otion Processing'Unit,
If water level is above casing,use"+' f 1617 Mail Serviu
ce 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
12.Well construction method: Air Rotary
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(1.e.auger,rotary,cable,direct push,etc.) { _
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service renter,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 1 Method of test: , 'Air 24c.For Water.Supply&injection Wells: in addition to sending the form to
• t the address(es) above,.also stibmii one copy of this form within 30 days of
13b.Disinfection type: 70%HTH , Amount: ; 2404 completion of well constructtonf 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