GW1--03590_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (UW-I) For Internal Use Only:
1.Well Contractor Information:
Frankle L.Oliver 14.WATER ZONES
FROM TO D£.SCHIP77(1N
Well Contractor Name 82 (` 421 f`.
3002-A 435 ft- ft.
NC Well Contractor Cettificatirm Number 15.OUTER CASING(for ntulti•cased wells)OR LINER(If ap icablel
Carolina Well Drilling FROM _TO I,I tMETER THICKNESS M(]'F.RIAL
0 ft• 46 ft' 61/4 in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal claced•ioop)
2.Well Construction Permit#: 23-314 FROM TO DIAMETER THICKNESS MATERIAL
Lit all applicable well construction permits(i.e.U1C County,State,Variance,etc.)
ft. ft. In.
et. ft. In.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN: FROM TO DIAMETER SLOT SIZE. THICKNESS M,%TERI AL
()Agricultural ()Municipal/Public ft. n. iu.
Geothermal(Heating/Cooling Supply) silResidential Water Supply(single) et, n. M.
bIndustrial/Commercial DResidential Water Supply(shared) IN.GROUT
()Irrigation FROM ....TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ f`' Bentonite Pour(17)50Ib Bags
Monitoring ()Recovery ft. — ft. —
njectiob Well: rt. ft.
()Aquifer Recharge DGroundwaterReinediation 19.SAND/GRAVEL PACK(If applicable)
()Aquifer Storage and Recovery ()Salinity Barrier FROM To MATERIAL. F.MITACF.MENT MF.TROD
DAquifer Test ()Stonmwater Drainage Ft. I t.
3Experimental Technology ()Subsidence Control It. it.
'Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardntas,sun/ruck type,graln size,etc.)
'Geothermal(Heating/Cooling Return) f)Other(explain under#21 Rernarks( 0 ft- 5 It Red/Brown Clay
4.Date Well(s)Completed: 5 3 24 Well ID# 5 rt. 25 ft' Brown Shale Rock
Sa Well Location:
25 it 750 f`' Blue Slater _ .
rt. rt. `�..uL_', ED
Jeffery Hinson
Faci
lity IDN(if applicable) ft. to.
FaeaitylOwnerNarue JUN 1 . 2024
3728 Wolf Pond Rd. Monroe 28112
ft. ft.
rt. ft. trriarrrs<+~r ?'�'aws^.; tJi*�
Physical Address,City,and Zip CM( 3(,�;
04-171-013 M.REMARKS
Union _
County Parcel Identification No.(PIN) —'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lst/long is sufficient) 22.Certification:
34.54.49 N 80.32.50 W C 5-31-24
Signature of Certified Well Contractor Date
6.Is(are)the welAs)aPermanent or ()Temporary
By signing this,lbrm. I hereby certify that the weU(s)mu(were)constructed in accordance
7.Is this a repair to an existing well: D yes or 9No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction Informutiun etplaiu the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 750 (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multipk welts List all depths if different(example-3t 200'and 2®100') construction to the following:
10.Static water level below top of casing:
19 (fr) 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 (ht.) 24b.For Injection Wag: 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,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test:
Air 24c.f or Water Suunly &infection Well': in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
70%HTH Amount: 42oz completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016