GW1--04889_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information;
Frankie L.Oliver 14.WATER ZONES
FROM To DESCRIPTION
Well Contractor Name 155 [t n
3002-A n, ft.
NC Well Contractor Certi(ic.uuwNisnber IS,OUTER CASING(fortuuldeued wells)OR LINER(if a !cable)
Carolina Well Drilling FHom To moist EH OLAU
t THICKNESS NI%Tk .
Company Name 0 n' 44 ft- 61/4 in' SDR21 PVC
16.i NER CASING OR Ti BLNG(geothermal clased.loopl
402320
2.Well Construction Permit#: nom _ To DIAMETER THICKNESS NIATF.U1Al.
Liu all applicable well construction permit+(Lc WC.Cawr(E,.halt,barianre,etr.l ft. ft. In.
3.Well Use(check well usek ft. h. In
Water Su 1•Well: 17,SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural 0Municipal/Public ft. ft, hi,
a Geothermal(Heating/Cooling Supply) 5aResidential Water Supply(singlet ft. ft, sn.
0Industrial/Commercial DResidential Water Supply(shared) is.cRouT
"irrigation no& TO MATERIAL _ F.MPI.ACEMENT METHOD a AMOINI
Non•WaterSupply Well: 0 ft' 20+ ft' Bentonite Pour(10) 50Ib Bags
Monitoring 0Recovery ft. ft.
jecdon Well; It. It.
0 Aquifer Recharge 0 Ground water Remedianon iv,+dANU/GRAVEL PACK Of auDllcllbte)
0 Aquifer Storage and Recovery D Salinity Banter 11tus , TO MATERIAI. EMPLACEMENT METHOD
0 Aquifer Test 0Stomiwater Drainage —
ft, rt.
0Experimental Technology DSuhsidence Control It. ft.
D(ieothennal(Closed Loop) DIracer 10,DRILLING LOG(attach additional sheets if necessary
]Geothermal(Heating/Cooling Return) [,other (explain under M21 Remarks) FROM rU ur ed ClayIPTIoN irulur,'wanes.,adVrucM type,ardhr sl:y e1cJ
0 rt' 8 ft' Red Clay
4.Date Wells)Completed: 7-1-24 Well IDS 8 It. 16 ft' Brown Clav/ShelQ
Sa,Well Location: 1s n' 200 n' Granite
a .
Barrett&Tiffany Hocutt ft. n. ` . `..,�_ ,`s 1.-
Facility'Owner Nate Facility IDN t if applicable) rt. tt.
4521 Renee Ford Rd. Stanfield 28163 ft. ft. AUG Q s 2024
Physical Address,City,and Zip It. ft lr..'.T.'... 1..'.••1;';.. ':7...
Stanly 140964 i 21,itEMARKS
County Parcel ldeatification No.tt'INi
Sb.Latitude and longitude hi degrees/minutes/seconds or decimal degrees: L
tit well field,one latrlong is suffxient) 22.Certification:
35.11.12 N 80.28.40 W
r 7.3-24
6.Is(are)the wellta)6aPennauent or Temporary Signature of Certified Well Contractor [)au
Ai tinning Mu form. I hereby certify that the well(s) war(were)constructed to an-onk:mc
7.is this a repair to an existing well: OVes or 5allo with I3A NCAC 02('.0100 or 15A NC.4('02C 0200 Well Construction Standard+and that a
If this is a rrpuir,fill uW loomsn'cll r ontstructiun WM-motion and rapluut tin nuu ns of lh, ropy s(rho record has been pnovtded to the well owner
repair wider#21 remarks seance or on the back of this farm.
23.Site diagram or additional well details:
if.For(teoprohe/DPT or(aosed•Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction details.
construction,only 1 GW.I is needed. Indicate TOTAL NUMBER of wells You may also attach additional pages if necessary
drilled' `t'B\iITTttl1,INSTRt'CTiONti
9.Total well depth below land surface: 200 ill I 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple vent but all&ymltt ifdi•rrnt 0.tawpl:•.3in 100'and ltn 100') Construction to the following:
tn.Mantle water level below sop of taming: VI t n.r Division of Water Resources,hunt mutton Processing Unit.
ifra#r Inv!u above carige.nee"' " 1617 Mail Service Center.Raleigh.NC 27699.1617
11.Borehole diameter: 6 (In.) 24h.For inlectfon Welk: hi addition to sending the funs 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
13e.Yield(gpm) 12 Method mf tr.1: Air 24c.For Water Suooly & iniecdan Wells; in addition to sending the fain to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 12oz completion of well construction to the county health department of the county
where constructed.
Form ow-I North Carolitu Department of Erre,onmenlal Quality-Division of Water Resources Revised 2-22.2016