GW1--04888_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
55 ft. 66 fL
3002-A
95 fit. 173 ft
NC Well Contractor Certification Number 15.OUTER CASING(far multi-caned wells)OR LINER((applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 43 fit 6 114 in. SDR21 PVC
Company Name
16.DINER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 122558 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable net!construction permits(ic. UIC,County,State,Variance,etc) ft. ft. is
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMu nicipal/Public ft. ft. In.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft, in.
0Industrial/Commercial Residential Water Supply(shared) in.GROUT .
,Irrigation FROM TO MATERIAL EMPLACEMENT METHOD C AMOUNT
Non-Water Supply Well: 0 ft 20+ fit- Bentonite Pour(13)501b Bags
QMonitoring °Recovery ft. a.
Injection Well: ft. rt.
Aquifer Recharge ()Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
0 Aquifer Storage and Recovery EDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
g Aquifer Test DStormwater Drainage rt. rt.
Experimental Technology OSubsidence Control ft. It.
0 Geothermal(Closed Loop) EpTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION icater.hardness.soil/ruck type,grain afar,etc.)
Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks)
0 it 8 m Brown Clay
4.Date Wells)Completed: 5-28-24 Well 11)4 8 fL 13 fL Brown Dirt/Rock
5a.Well Location: 13 fit. 225 ft. Blue Slate
Crystal Conner it. ft. k
Facility/Owner Name Facility ID#(if applicable)
ft. rl. `� t -, ,
7084 Queens Dr.Stanfield 28163 fit. rt. AUG 2, S '074
Physical Address,City,and Zip a. ft.
Stanly 33571 21.REMARKS I'.)."d=:. i � -'-
County Parcel Identification No.(PLN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one at/long is sufficient) 22.Certification:
35.12.16 N80.26.46 W C:."
5-31-24
6.Is(are)the well(s)ElPerInanent or Temporary Signature of Certified Well Contractor Date
By signing this fonts. I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Eallo with 15A NG4C 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constnectionr information and expluiu the nature of the copy of this record has been provided to the well owner.
repair under N21 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: SLBMI'l 1 AL INSTRUCTIONS
9.Total well depth below land surface: 225 1ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths if different(example.3t.200'and 2QI00') construction to the following:
10.Static water level below top of casing: 25 _ifs.-) 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 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,NC 27699-1636
13a.Yield(gpm) 3.5 Method of test: Air 24c.For Water SauDly & infection 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: 150Z 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