GW1--05114_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 DESCRIPTION
Well Contractor Name
3002-A 73 ft. 134 rL
163 f`' f
NC Well Contractor Certification Number 15.OUTER CA6iNG(tor could-eased wells)OR LINO(If a)
Carolina Well Drilling FROM DIAMETER THICKNESS MATERIAL
0 ft. [Tr
44 ft- 61/4 in' SDR21 PVC
Company Name 16,INNER CASINO OR TQAI<NG lirpothertnal cialed4eop)
2.Well Construction Permit#: 24-17 FROM TO DIAMETER THICKNESS MATERIAL
Tact all applicable well ranctruction permits(i.e. UIC,Cnunty,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): •ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
)Agricultural QMunicipal/Public ft. n. in.
)Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
n. n. in.
)Industrial/Commercial ()Residential Water Supply(shared) IN oov,1,
nlrrigation FROM TO MATERIAL EMPLACEMENT METHOD a AMOUNT
Non-Water Supply Well: 0 ft• 20+ ft. Bentonite Pour(10)50Ib Bags
°Monitoring ()Recovery rt. ft.
Injection Well: et ft — —
)Aquifer Recharge ()Groundwater Retnediation 19.SAND/GRAVEL PACK Of appNeabie)
•
)Aquifer Storage and Recovery )Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer Test 0Stoimwater Drainage ft. ft.
Experimental Technology )Subsidence Control ft. ft.
Geothermal(Closed Loop) )Tracer 30.DRILLING LOG{tdlag6 nir)idat)uil sheets it necessary)
)Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION wafer,hardness,son/rock type,grain sire,etc)
0 ft' 10 ft' Red Clay
4.Date Welts)Completed: 6-21-24 Well ID# 10 ft' 19 IL Brown Clav
5a.Well Location: 19 ft. 175 ft' Blue Slate _�
ft. ft. t 1�.•„
Mark Penegar _ . . '1/4.-... . i/ 1._.IL..•
Facility/Owner Name Facility IDf applicable) tt ft
N o
Ellis Griffin Rd.Marshville 28103 rt. rt. AUG 2 7 t024
Physical Address,City,and Zip ft fL
Union 02-236-006B 2f.REMARKS
County Parcel Identification No.(PIN)
513,Latitude and longitude in degreeshninutes/seconds or decimal degrees:
,if well field,one lat/long is sufficient) 22.Certification:
35.10.10 N 81.25.20 W
6-25-24
)Temporary . Signature of Certified Well Contractor Date
6.Is(are)the weB(s)61Pennanent or
9y signing this loon. 1 hereby cert(fy that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or Eallo with 15A NCAC 02C.0100 or 15A 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 roofer#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: 175 ('L) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple went list all depths if different(example-3[ta,200'and 2®100) construction to the following:
10.Static water level below top of casing: ti (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing,arse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 ((n.) 24b.For Iniection Wells: In addition to sending the farm 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) 50 Method of test: Air 24c.For Water Suuuly & Iniection 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: 12oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department 0 Environmental Quality-Division of Watcr Resources Revised 2-22-2016