GW1--02200_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: .
Frankie L.Oliver iklitWATER',ZO.ES ,'-4 'r t'gcttk ,,. ,i,:.=' < ; ..-;., 5 '..
Well Contractor Name FROM TO DESCRIPTION
3002-A 115 ft- 310 ft- I '
ff. fL
NC Well Contractor Certification Number i yg;Q11TERCASINGt(foe=mild:eoieed wellsl'•ORiLINER`(If ap lletibIt -
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 it 45 ft. 6 1/44 1n' SDR21 PVC
24-19 `-'e16INNEICCASINGOR,TUBINGTgeotheYniuttlasedlloop)'; `�' )-' ""+; '*..'
2.Well Construction Permit#: • FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. ft. I' in.
3.Well Use(check well use):
ft. ft. ; in.
A .SCREEN.-,._,a ,` `3 lt..,.,( .�,t n p ' u;. +a. . . a a: y ..,,.`-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. In.j
Geothermal(Heating/Cooling Supply) 'EaRcsidcntial Water Supply(single) ft. ft ' tn.; ,
Industrial/Commercial , DResidential Water Supply(shared) 111.:GROUT. !,, „ t� ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 •ft' 04-L Bentonite Pour(12)50Ib Bags
Monitoring , E3Recovery fL ft.
Injection Well:
rt. rt. I.
Aquifer Recharge E3Groundwater Remediation
:19.'SAND/GRAVEL-PA(K=(ifapplicitble) .. f _ .,c i.
Aquifer Storage and Recovery • DSal tatty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. rL !
Experimental Technology ,Subsidence Control ft. ft. '
Geothermal(Closed Loop) OTracer .,'20:U1tII:L1NG,LOG,hitt<nCliiidditiOinlISheet6`,ifacCesSury)r ,','„" t ,.r,
FROM TO DESCRIPTION(color,hardness,sull/rock type,groin she,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#2I Remarks)
0 ft- 17 ft. Brown Clay/Rock
4.Date Well(s)Completed: 3-5-24 Well ID# 17 re. 325 ft' Granite
5a.Well Location: ft. ft.
Ashton Little et. rt. r
Facility/Owner Name Facility ID#(if applicable)
iL ft. a t. t:..r' I t: I..,:>:_.<
5505 Jerusalem Church Rd.Marshville 28103 ft. ft. I APR 0 s 2074
Physical Address,City,and Zip ft. ft. ,
Union 01-106-011A 21;REMARKSa,,,'t.4 r rs.,4 ::., . , y;Il,v .,r * +, r 5 x. y_iJ,sa
L!d YE 6'Ji
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - ,
(if well field,one Lit/long is sufficient) 22.Certification:
35.10.810 N 80.31.666 W 3-15-24
6.Is(are)the wcll(s)EaPermanent or Ei Ternporary Signature of Certified Well Contractor 1 Date
By signing this form.I hereby certify t/tat the well(s)was(were)constnicted in accordance
7.Is this a repair to an existing well: IJYes or igNo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Wen Construction Standards and that a
If this is a repair,fill out known well construction information and etplai(the nature of the copy of this record has been provided io the well owner.
repair under N2l 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 alsi attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit tliis form within 30 days of completion of well
For mullipte wells list all depths if different(ewmple•3V00'and 2Q100) construction to the following: I
t
10.Static water level below top of casing: 30. (ft.) Division of Water Resources,Information Processing Unit,
!jwater level is above casing,use"+" 1617 Mail ServicelCenter,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 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: Air 24c.For Water Supply&iniel Hon Wells: In addition to sending the form to
the address(es) above, also sutirriit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 20oZ 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 es Revised 2-22-2016
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