GW1--05106_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DFSCRiPT10N
Well Contractor Name
161 ft. fa
3002-A -rt. n
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(If ap llcable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 56 it' 61/4 in' SDR21 PVC
Company Name 16.INNER CASING OR TUBLNG(geothermal cloced•loop)
2.Well Construction Permit it; 24-46 FROM TO DIAMETER THICKNESS M TERIAI.
Litt all applicable well cantrructinn permits(i.e.RAC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. In.
17.SCREEN
Water Supply Well:
PP 5 FROM 'I() DIAMETER SLOT SIZE THICKNESS MATFRIAL
Agricultural 0Municipal/Public ft. ft. in.
[Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) '— ft. n. in.
[industriaiCommercial DResidential Water Supply(shared) IN.GROUT
I1irrigation FROM TO MATERIAL EMPLAUV..MFN-r METHOD a.AMOUNT
Non-Water Supply Well: 0 ft* 20+ rt, Bentonite Pour(13)50Ib Bags
Monitoring [Recovery rt. rt.
Injection Well: rt. ft,
Aquifer Recharge [Groundwater Remediation
19,SAND/GRAVEL PACK(It applicable)
Aquifer Storage and Recovery [Salinity Barrier FROM TO) MATERIALEMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage It. I I.
0
Experimental Technology [Subsidence Control ft. It.
OGeothetmal(Closed Loop) [Tracer 20.DRILLING LOG lattach additional sheets if necessary)
[Geothermal(Heating/Cooling Return) [Other(explain under M2I Remarks) FROM TO DESCRIPTION stater,hardwtsc,salUrotk type,grain srxt etc)
IL 8 ft' Red Dirt
4.Date Well(s)Completed: 5-20-24 Well IDS 8 ft' 18 rt' Brown Clav/Shale
Sa.WeU Location: 18 ft" 250 It Granite -- ..
Montana Price ft. rt. t..r` ,4-,
Facility/Owner Name Facility IDS(if applicable) rt ft ' 1•- �'t
3224 Sikes Mill Rd.Monroe 28110 n• rt. AUG 2 i 2U24
r4 rt.
Physical Address,City,and Zip
Union 08-129-028 2I.REMARKS , _,_______
County Parcel Identification No.(PiN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablong is sufficient) 22.Certification:
35.50.55 N 80.29.35 W
5-31-24
6.is(are)the well(s)5aPermanent or OTemporary Signature of Certified Well Contractor Date
BY signing this.form. 7 hereby cergfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ®No with RSA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standar&and that a
If this is a rs)stlr,fill unt known well construction infurmatiun and captain the nature of the cops of this record has been provided io the well owner.
repair tinder 021 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-I 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: 250 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample•3(,200'and 2@I00') construction to the following:
10.Static water level below top of easing: 30 (n.) Division or water Resources,Information Processing Unit,
If water level u above casing,use'•*•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dlanreter: 6 (In.) 24b.For Infection Wells: In addition to.ending 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 Mall Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 7 Method of test Air 24c.For Water Supply & 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% HT Artiirnnt: 2802 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Dcpartmcnt of Environmental Quality-Division or Water Resources Revised 2-22-2016