GW1--00972_Well Construction - GW1_20240208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver `r14.WATER ZONES ,,,._u .. .
Well Contractor Name FROM TO DESCRIPTION
332 ft- et.
3002-A ft, ft.
NC Well Contractor Certification Number 35.OUTERCASING(for nipin cased_Wells)OR LINER,(if applicable)
Carolina Well Drilling FROM To DIAMETER , THICKNESS MATERIAL
0 ft' 44 ft' 6 1/4 I it,' SDR21 PVC
Company Name
'16aINNER CASING OR TUBING°(Redthernial closed-loop),' , , ,^,•:
Z.Well Construction Permit#: 23-226 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LUC,County,Stare,Variance,etc.) 0 ft' 80 ft- 4 i in. SCH40 PVC
3.Well Use(check well use): ft ft. in
Water Supply Well: 17.SCREEN . �,_ ,,.,
FROM TO DL4METE1 SLOT SIZE THICKNESS MATERIAL
Agriculhual DMunicipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) j!QlResidential Water Supply(single) fL ft. in
Industrial/Commercial DIResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD dt AMOUNT
Non-Water Supply Well: 0 ft- 20+ ft. Bentonite Pour(7)50Ib Bags
Monitoring f Recovery 0 ft' 80 ft. Portland Pour(9)47Ib Bags(4")
Injection Well:
ft. ft.
Aquifer Recharge DIGroundwater Reined iation• „ty,SAND/GRAVEL-PACK(if applicable) °°'
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. ,
Experimental Technology OSubsidence Control ft. ft. ,
Geothermal(Closed Loop) QTracer '20.DRILLING LOG(attach additional sheets,if necessary) -- . '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
0 ft• 13 ft. Brown/Red Clay
4.Date Well(s)Completed: 12-29-23 Well ID# 13 ft- 350 f`' Blue Slate
5a.Well Location: ft et : 7'°l -°'! ;+••,s•-
Allison's Custom Construction it ft. 1 �:i"`Lse � •,
Facility/Owner Name Facility ID#(if applicable) ft. et FEB 0 R 2024
3516 Richardson Rd. Monroe 28112 ft. ft.
Physical Address,City,and Zipft. ft. I'(IYtiiis44ilr'7 P•t`f"`09'r a ijr''
YS D'lAr't`.rl'('rlG
Union 04-198-002U 21:,RENIARKS >; .. = ', u,,1. ..,,: s 4t.
County Parcel Identification No.(PIN)
*Installed 4"liner to seal off bad iron seam at 75'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la/long is sufficient) 22.Certification: i
34.90.683 N 80.57.093 W
1-4-24
6.Is(are)the well(s)EtPersnanent or Temporary Signature of Certified Well Contractor Date
By signing this form, 7 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or dI No with/5A NCAC 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 '
9.Total well depth below land surface: 350 (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 1Q100) construction to the following:
10.Static water level below top of casing: 60 (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 (ill.) I
24b.For Injection Wells: In addition to sending the fume 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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ 8 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: 22oz 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