GW1--02202_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: . '
1.Well Contractor Information: ; r
Frankie L.Oliver 14.WATER ZONRS r ,t,.:;« n? 41g v.._,,-1.; ,tF : . t a K:.j, ,Y 3<
WellCon[rscturNamc FROM To DESCRIPTION
3002-A 64 fO 104 ft- 1
517 ft' ft.
NC Well Contractor Certification Number tu15 OUTEICCASE GIfottl'iudltl-cased`I ells):OR,LINER;(ltap i8cable) ;l;
Carolina Well Drilling FROM TO DIAMETER:, THICKNESS. MATERIAL
Company Name 0 ft. 44 - ft* 61/4 ,in' SDR21 PVC
23-328 i16lINNER CASING OR TUIIING;(geothernial`clas'ed-loop)'ti , t
2.Well Construction Permit 41: FROM TO . DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. fL ' 'In.
3.Well Use(check well use): ft, ft, in-
t 17:SCREEN IP; ,ii 's`,1',il . 1 i ' y{. '''ri'.. k`'.e
Water Supply Well: FROM " TO DIAMETER, ,SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) '5aResidential Water Supply(single) ft. it, in.:
DIndustriaVCommerciai DResidential Water Supply(shared) .Is GROUT:r<",r•i:,i.., t . ..:'n ':;'i ',. .
IiIRigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ fr. Bentonite Pour(14)50Ib Bags
Monitoring ORecovety ft. ft.
Injection Well: ft. lc.
Aquifer Recharge I Groundwater Remerliation ely.SAND/GRAVEL TACK(trapplicithle) -'2'.!'4; :`i:' `;a. r,x Ar,: , .
0 Aquifer Storage and Recovery OSalinityBarrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage
rt.
Experimental Technology QSubsidcnce Control ft. ft.
Geothermal(Closed Loop) Tracer uJ.20:-DRII LING�I QG`'(iit'rieh additionalsheetsitnecessary)1 F '. e:ii?:t ..
FROM TO DESCRIPTION(color,hardness,suit/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 e- 7 ft- . Brown;Clay
4.Date Well(s)Completed: 2-19-24 Well ID# 7 ft' 625 re' Blue Slate _
ft. ft. I 77.:::: _T, - p. .0
`t r
5a.Well Location: ,:--`.-.? a/ s,.•-•-.�..:J'
Rurrell Bryant ft. ft. 1 rr11
24
Facility/Owner Name Facility ID#(if applicable) it. rt. A �U
2801 Henry Baucom Rd.Monroe 28110 ft. ft _ - Unk
Physical Address,City,and Zip It. ft. [N/Cg T O(j
Union 08-072-009F =e21;;REMARKS,.iK's.,, ,-7 .,ii r a, r;<<. Y 1):, l 1"a? •:i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification: '
35.10.014 N 80.46.018 W
3-15-24
6.Is are the walls .Permanent or Temporary Signature of Certified We Contractor Date
By signing this•fonu, I hereby certjfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
ff this is a repair,fill out known well construction Mformation 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•fonu 23.Site diagram or additional wlell details: •
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sameYou 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
i
9.Total well depth below land surface: 625 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr nutltipk wells list all depths if different(example.3tcy200'and 2@100) construction to the following:
33 1
10.Static water level below top or casing: (fY-) Division of Water Resources,Information Processing Unit,
Ifwaater 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 farm to the address in 24a
Air Rotary above,also submit one copy ofthis form within 30 days of completion of well
12.Well construction method: construction to the following: I.
(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) 4 Method of test: Air 24c.For Water Supply&.injection Wells: in addition to sending the form to
the address(es) above, also sutimit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 3802 completion of well constructio I to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division ot•Water Resources Revised 2-22-2016