GW1--03594_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DF.S('RIPTION
Well Contractor Name
131 f` 237 R.
3002-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for muld.cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM Tt) DIAMETER IIIIC KM-SS MATERIAL.
0 ft. 92 ft. 61/4 in' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
23-182
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS \I VIE RI U.
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. ft. In
3.Well Use(check well use): ft. ft i`t
17.SCREEN
Water Supply Well: FROM 'I'O DIAMETER SLOT SIZE THICKNESS NI VI F:IttAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) it. ft. in.
Industrial/Commercial DResidential Water Supply(shared) ls.GROUT
Irrigation FROM TO M ATF.RIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R. 20+ ft' Bentonite Pour(28)50Ib Bags
Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
aquifer Storage and Recovery EjSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage It. ft
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION i color.hardness,soil/ruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) [Other(explain under#2I Remarks)
0 ft' 8 ft' Brown Clay
4.Date Well(s)Completed: 3-26-24 Well ID# 8 ft. 80 f`" Brown Sand/Rock
5a.Well Location: 80 ft- 85 fr. Brown Rock
Oleg Davidov 85 it. 275 ft. Granite
Facility/Owner Name Facility 1D#(if applicable) ft. ft. •;`. `�`. �• ,V/�1.J1
2418 Cherrywood Ln.Matthews 28104 Providence Place#72 ft. ft
it. rt. JUN 1 3 2024
Physical Address,City,and Zip
Union 06-063-151 21.REMARKS rt UiHI
County Parcel Identification No.(PIN) p`Ned 30u
5b.Latitude and longitude in degrees/minutes/seconds or dechnal degrees: --
(if well field,one lat/Iong is sufficient) 22.Certification:
35.03.636 N 80.70.674 W
4-1-24
6.Is(are)the well(s)laPennanent or OTemporary Signature of Certified Well Contractor Date
By signing this form. 1 hereby certify that the sells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or gNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out know(well construction information and ctplain 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: 275 Kt) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple went list all depths if different(example-3(&200'and 2®100) construction to the following:
10.Static water level below top of casing: 5 (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 Inflection 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,NC 27699-1636
13a.Yield(gpm) 8 Method of test: Air 24c.For Water Slimily & Inlection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 18oz 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 Revised 2-22-2016