GW1--05104_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO t DESCRIPTION
172 ft- 417 ft'
3002-A ft.438
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a llcable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 44 ft. 61/4 in' SDR21 PVC
24-20 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lin all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): it. ft in
Water Supply Well: 17.SCREEN
FROM TO
Agricultural OMunicipaUPublic rt. rt. DIAMETER SLOT SIZE THICKNESS ]Lr"f ratl U.
In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
Industrial/Commercial
Irrigation
Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD di AMOUNT
Non-Water Supply Well: 0 it 20+ ft- Bentonite Pour(13)501b Bags
Monitoring
Injection Well:
Recovery et. rt.
f[ rt.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACE(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
JAquifer Test jStormwater Drainage R. rt.
Experimental Technology D Subsidence Control ft. ft_
Geothermal(Closed Loop) OTracer U.DRILLING LOG(attach additional aheets if necessary)
0 Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION ludo.,hardness,suil/reek type,grain size,etc.)
( g g [Other(explain under#21 Remarks)
0 ft. 8 ft. Orange Sandclay
4-Date Well(s)Completed: 5-22-24 Well IDl1 8 rt. 16 it. Brown Dirt/Rock
5a.Well Location: 16 ft' 450 rt. Blue Slate
Deidra Cribb rt. rt.
Facility/Owner Name Facility ID#(if applicable) rt. ft `:-.•. .... ! , 1
Sikes Mill Rd.Monroe 28110 ft. ft.
AUG 9 r' �414
Physical Address,City,and Zip rt. ft.
Union 08-129-012G 21.REMARKS ii _ _ _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
35.50.45 N 80.29.41 W �) —
_� 5-31-24
6.Is(are)the wcl](s)EaPermanent or Temporary Signature of Certified Well Contractor Date
By signing this,form. 1 hereby certjf,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or UNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain 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 Geoprohe/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: 450 (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3g200'and 2Q/00') construction to the following:
10.Static water level below to33
p of casing: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (hi.) 24b.For Injection 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.c.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) 13 Method of test: Air 24c.For Water Supply& Injection 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: 28oz 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