GW1--01025_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES ,
FROM To DESCRIPTION
Well Contractor Name
3002-A 137 ft' 463 ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 62 ft' 61/4 in' SDR21 PVC
Company Name ' 16 INNER CASING OR TUBING'(>eothern al closed-loop) '
2.Well Construction Permit#: 23-191 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): fa ft in.
Water Supply Well: FROM
REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) !diResidential Water Supply(single) ft. it. in.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft. Bentonite Pour(17)50Ib Bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. it
Aquifer Recharge I0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) •
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage et. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.1)RILLING,LOG(attach additional sheets if necessary)•.
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/ruck type grain size,etc.)
0 it 27 it Brown Clay
4.Date Well(s)Completed: 12-7-23 Well ID# 27 ft' 35 ft. Brown Shale
5a.Well Location: 35 ft- 600 ft' Blue Slate
Ashley Couick fc rt. I:•. t v .:
Facility/Owner Name Facility ID#(if applicable) ft. ft. G }-,'
1012 E. Sandy Ridge Rd. Monroe 28112 et. fL FEB `0 8 2024
Physical Address,City,and Zip ft. ft. lihti 7F1i ct{A P,rn
Union 04-120-002B 21.REMARKS (}!/.i ftoz' * �I`R
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
•
34.89.393 N 80.52.121 W
12-11-23
6.Is(are)the well(s)0Perinanent or ❑II 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: $Yes or j!ai No with ISANCAC 02C.0100 or 15ATICAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out ATOM!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 backof 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: 600 (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:
10.Static water level below top of casing: 27 (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.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test: Air 24c.For Water Supply &injection 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: 70n/o HTH Amount: 360Z completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolina Department ot'Environmental Quality-Division of Water Resources Revised 2-22-2016