GW1--02204_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver la..WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
129 ft. 238 ft- I !
3002-A I ;
ft. ft.
NC Well Contractor Certification Number
.15.OUTER CASING(for tnalti=casedwells)OR'LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 57 ft In SDR21 PVC
Company Name 161NNER CASING 0R TUBING(Reoiherttial closed•lobp)
24-16 FROM TO DIAMETER
2.Well Construction Permit it: THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. its
Water Supply Well: i7.SCREEN. •', F" "
pp y FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL _
[DAgricultua1 r3Municipal/Public ft. ft. II. r
0 Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in-
DIndustrial/Commercial OResidential Water Supply(shared) ;ltt:GROUT '
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft* Bentonite Pour(17)501b Bags
Monitoring (DRecovery ft. ft.
Injection Well:
ft. re.
Aquifer Recharge ID Groundwater Remediation i
19.`SAND/GRAVEL,PACE(if applicable)., .* .- t '' " -
0Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft.
Technology Subsidence Control ft. ft.
(Closed Loop) O
Tracer :':20.DRILLING LOG(attach additionaFsbeets if necessary) if
O
Geothermal(Heating/Cooling Return) ',Other(explain under#2I Remarks) FROM TO DESCRIPTION(colur,hardness,sail/rock type,grain size,etc.)
0 f4 34 ft Brown-Clay
4.Date Well(s)Completed: 3-21-24 Well ID# 34 ft 250 ft.
Blue:Slate
5a.Well Location: ft. ft. f._ 2..'°w 'w� •.. --..i T. .
fL ft. I { �...,✓...lJi.
Gary Griffin APR o g LUZ4
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3822 Marshville-Olive Branch Rd.Marshville 28103 rt. ft In,v;,^;,;,i ,--:-.: Iry
Physical Address,City,and Zip ft. ft. [3Z v it u'ai
Union 01-075-010B 21.REMARKS ^{'•.
i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.06.755 N 80.32.186 W 3-28-24
6.Is(are)the well(s)ElPennanent or OI Temporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or >i,No 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 etplain 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: .. 250 (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(a.200'and 2@100') construction to the following:
10.Static water level below top of casing: Z8 (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: 1 ,
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service renter,Raleigh,NC 27699-1636
13a.Yield(gpm) 23 Method of test: Air 24c.For Water Supply&injection Wells: In addition to sending the form to
the address(es) above, also sub it one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 15oz completion of well constructionitol 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