GW1--05113_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
108 R. 238 n.
3002-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licablel
Carolina Well Drilling FROM TO DLAMETER THICKNESS MATERIAL
Company Name 0 IL76 rL 61/4 in' SDR21 PVC
16.INNER CASING OR TUBING(geothermal dosed-loop,
23-224
M
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS ATERAAI.
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc) ft. ft. is
3.Well Use(check well use): ft. fL in.
Water Supply Weil: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS \IATLMA I.
°Agricultural °Municipal/Public ft. ft. tn.
Geothermal(Heating/Cooling Supply) IAResidential Water Supply(single) it, ft. In.
0 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
(,Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rL 20+ ft. Bentonite Pour(8)50Ib Bags
QMonitoring °Recovery rt. ft.
Injection Well: rL rt
bAquifer Recharge DGroundwaterRemediation 19.SAND/GRAVEL PACK(If applicable)
Q Aquifer Storage and Recovery E 3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Q Aquifer Test 13Stormwater Drainage
rt. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) DTraccr 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION,color,hardness,soil/ruck type,train size,etc)
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks)
0 ft. 6 ft. Brown Clay
4.Date Wells)Completed: 6-12-24 Well ID# 6 t`' 20 t`' Brown Clay/Shale
5a.Well Location: 20 ft. 250 ft. Granite
Allison's Custom Const.LLC It. rt. '`• •I 1-' ?
Facility/Owner Name Facility ID}t(if applicable)
It. AUG 2 i 2024
3512 Richardson Rd.Monroe 28112 ft. ft.
--�t., 'JI'li
Physical Address,City,and Zip D. ft. r.
Union 04-198-002T 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.28 N 80.34.19 W
7-3-24
6.Is(are)the well(s)42Pennanent or QTcmporarp Signature of Certified Well Conusctor Date
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or sNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 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: 250 eft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-34,200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: 22 (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 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) 4.5 Method of test: Air 24c.For Water SUDOly& 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: 16oz 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