GW1--02232_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.Well Contractor Information: j ,
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Frankle L.Oliver (ia:ill'ATER ZONES . ;t _ni 4 ...' tot -, . x, n . , s t,;
Well Contractor Name FROM TO DESCRIPTION
80 ft• 111 ft. i'
3002-A 159 'ft' 438 ft'
NC Well Contractor Certification Number x15:':OUTER'.CASING;(far lwltl case'd'tvteltk)OR?I INET+(3f appHeablel .,:+.`a i,•:
Carolina Well Drilling FROM TO DIAMETER f THICKNESS . MATERIAL
CampanyNamc 0 ft. 43 . IL. 61/41 i" , SDR21 PVC
r16,1INNER CASING'DICIETBING;(cotheritiirelo notsed4An I IN
2.Well Construction Permit#: 23-157 FROM TO DIAMETER . THICKNESS MATERIAL
List all applicable well consiradion permits(i.e.UIC,County.Stnte,Variance,etc.) ft. ft. r in.
3.Well Use(check well use): ft. ft. Ur
Water Supply Well: `a7'SCREENS •: x .s..,• .,.;;:,;,,k-tt , .,r, .x:, ''..;'.,,:?.° N._. c; c,;;:
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
Agricultural . Municipal/Public ft. ' ' ft, . in. I
Geothermal(Heating/Cooling Supply) oRcsidential Water Supply(single) it, ft, ,tn.' •
Industrial/Cotmnercial QRcsidential Water Supply(shared) lint:GROUTS °;;;u , . ., .' . . _."`.iW-F Ifi' 4, .at; ,...
Irrigation FROM To ' MATERIAL : EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ IL Bentonite Pour(13)50Ib Bags
Monitoring QRccovery ft. ft. 1
i'
Injection Well: ft. ft.
Aquifer Recharge .Groundwater Remediation 1'
t9 SANID/GRAVEL-E;%CK:(ifaUtilicablel ,.:. s- •t. S r.v=` t v.r_> '.;;,.',
,Aquifer Storage and Recovery .Salinity Barrier FROM TO . MATERIAL! EMPLACEMENT METHOD •
Aquifer Test 0SwmiwaterDrainage ft. R.
Experimental Technology 0Subsidence Control it. ft. '
Geothermal(Closed Loop) OTracer : ri+20 UItILI:1NG:I;OG fattii'ch'udditioiiatatieets ifrietessatyN: ,.., r,..ti•i:'
Geothermal(Heating/Cooling Return) Other(explain under#121 Remarks) FROM TO DESCRIPTION(eider,hardness,Sail/rock type,grain size,eteJ
0 Et• 6 , ft. Red Clay
4.Date Well(s)Completed: 2-21-24 Well ID# 6 It. 14 i•t. Brown Clay/Shale
5a.Well Location: 14 ft- ft, Granite i`
Antonia&David Slaybaugh fl, ft. ` h LA....,, �./`,fr— 1 t
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR 0 g 2024
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1503 Union Rd.Matthews 28104 ft. ft. I
II. ft. 1Pr`s, r i.
Physical Address,City,and Zip1 r- x W. g t:E a
Union 08-321-0104 €k2t;RE11tA'RKS:.'' t;ir`. ,1,1M .:.i ):r .„;, rrY4y ul4 ,,.`,,:.' ..
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladloing is sufficient) 22.Certification:
35.15.059 N 80.61.680 �, i
C_ b.e 3-15-24
6.Is(are)the well(s)EaPertnanent or IjTemporary Signature of Certified Well ContractorDate
By signing this form, I hereby certify that the Well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or SiNo with/5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
-If this is a repair,fill out brown wall corutruclion information and e.epktirr the nature of the copy of this record has been provided to the itch owner.
repair under#21 remarks section or on the back of this•ono. I.
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 necessaiy.
drilled: ,SUBMITTAL INSTRUCTIONS'
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9.Total well depth below land surface: 450 {£t.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3 ir200'and 2 100) construction to the following: '
i
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
/rimier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 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,NG 27699-1636
13a.Yield(gpm) .50 Method of test: Air 24c.For Water Sutluly &1niectiou Wells: in addition to sending the form to
the address(es) above, also submit tone copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 280Z completion of well construction to the county health department of the county
where constructed. I '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016