GW1--02199_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Frankle L.Oliver 1 5x, g a :•.1i%,,y p
FROM TO DESCRIPTION
Well Contractor Name
IL 145 22 fL7
3002-A
239 tt 272 IL 281,289,312
NC Well Contractor Certification Number 16 OUTER(CASING'-(for'niuld caseditvollsy.OR LTNERAf ap lleuble)< ", t.,<r
Carolina Well Drilling FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 ft' 44 Et' 6 1/4 l i°' SDR21 PVC
if•16.:INNER:CASING012TUBING.(geothermalcloscd4inin) .;'-zr , st;.-'`
2.Well Construction Permit#:
23-380 FROM TO DIAMETERTHICKNESS
' MATERIAL
List all applicable well construction perinits(ie.UIC,County,State,Variance,etc.) ft. ft. ( in.
3.Well Use(check well use): fa ft. j In.
"1.T'SOREEW3ef?s. t,;•a' T,!S v,,, „� +„.A4- :,. ,,,":,,i' i;«,, , ..,,
Water 5npply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) TL .n, in.
Industrial/Commercial • DResidential Water Supply(shared) 1H GROU1 u , xfi z,,. �..._, S{;t.:°nr `..',o 4,, ,,lP . ° :; ,•v,
Irrigation FROM TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ tti Bentonite Pour(10)50Ib Bags
Monitoring E3Recovery ft. ft. .
Injection Well: ft. rL
Aquifer Recharge E3Groundwater Remediation • I
P49.SAN13/GRAVEL:RACK,(if applicable) : ',u.,i. M \k , -0`,,---... .};,=`
Aquifer Storage and Recovery °Salinity Barrier FROM TO ' MATERIAL EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. . ft. !
Geothermal(Closed Loop) ['Tracer •`.20`:'D1tILLING .1FIG"(iittiichadditioiialnlieets if ueeessaryy^ +? t.-•d, a; +d,, ; )4
FROM TO DESCRIPTION(color,hardness,sutUreck type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#2I Remarks)
0 fL 10 fL Brown Clay
4.Date Well(s)Completed: 3-8-24 Well ID# 10 IL. 16 IL
Brown Rock
5a.Well Location: is ft- 20 fa Yellow Clay
Matthew Campbell 20 rL 360 IL Granite =- `. .4w;m y.i: >, ^I
Facility/Owner Name Facility ID#(if applicable) ft- ft. j
1471 Biggers Cemetery Rd.Marshville 28103 ft. ft- i APR 0 IT CO24
Physical Address,City,and Zip ft. ft. t L r r r FR i
Union 08-114-009V ;Y21:'REMARKS4k',f2 ,!:,,,'.., 1'W - '..,•`,sr'^2 .l-5 as ,. .tl.t,a I.Ai h r k'aruw
County Parcel Identification No.(PIN) '
,
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/loug is sufficient) 22.Certification:
35.17.097 N 80.50.038 W, ,X�y_.., 3-15-24
6.Is(are)the well(s)G3Permanent or Temporary Signature of CertifiedWWee11YContractori. Date
8y signing this,fomi.'1 hereby certjfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or isiNo with 15A 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 loathe 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.
I
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 360' (t'L) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudiiplc wells list all depths if different(example-3@200'and 2(4100') construction to the following: ''
10.Static water level below top or casing: 39 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27 69 9-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy oil 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) 17 Method of test: Air 24c.For Water Supply &Tnt ection 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