GW1-2021-01715_Well Construction - GW1_20210323

WELL CONS'PRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver ILWATER ZONES
FROM TO 11DFBCRIPTION
Well Contractor Narne
118 "' 140 n'
3002-A a
149
NC Wcll Contractor Certification Number 15.0
ING ter ruYlseri DRL R
Carolina Well Drilling FROM TO DIAMPT'P.R THICKHFsa MATF.RIAI.
C.upany Naive 0 n' 109 n' 1 61/8' 1" SDR21 PVC
20-112 1L CASWGO TURRIG
L Well Construction Permit#: mom To DLIMPTFR THICKNF3S MATF.RIAI.
list all applicable well raarrnarinn permi<r(i.e.VIC,CaanO,State.Varianrc,clr.) n. n. In.
3.Well Use(check well use):
Water Supply Well: 17 SCREEN
PPY FROM TO MAMErF.R RIAT RVY THICKNESS MATERIAL
Agricultural �Municipal/Public 0 R n. Is
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) M1 n, la
Indusif ial/Commereial DResidential Water Supply(shared)
lrrf align FROM TO MATERIAL EMPLACUWff METHOD A.AMOUNT
Non-Water supply Well: 0 n• 20+ n Bentonite Pour 23 501b Bags
Monitoring Recovery n. r.
Il�ecdon Well: ft. R
Aquifer Recharge OCmoundwater Remediation
It. RAVEL PACK K
Aquifer Storage and Recovery Osalinily Barricr PROM TO MATP.RIAI. I F.MW.ACP.MEW METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control n. a
Gentheimal(Closed Loop) QTracer X DRILLINGLOG(such sddld"obtain E
Geothermal(Ileatin Coolin Berson) nOther(exlain under#21 Remarks) van"' TO DPsCRIPrwN(color bars wuroskt um Her.)
0 n- 4 rt' Red Clay
4.Date Well(s)Completed: 3-8-2021 Well ID# 4 n' 97 n' Brown Sandclay/Rock
5a.Well Location: 97 n' 100 rt Brown Rock
-
Tanner Design &Build 100 1t' 200 ~ Granite
Facd,ylOwacr Name Facility lDa(Ifapplcabk)
6949 Huey Rd.Waxhaw 28173 Wildwood Place Lot#4 n. h.
Physical Address City.and Zip n' rt' I tLk 2
Union 05-104-035H 21.REMARKS
County parcel Identification No.(PIN)
5b.Latitude and longitude In degreeshadnutes/seconds or decimal degrees:
(if usil Wit...,tainting is sutficicn0 22.Certification:
34.49.34 N 80.43.39 W,
7 3-11-2021
6.Worse)the well(s) ,OPermaoenl or OTemporary SiVill1i of Certified Well Contractor Date
Ily signing Ihisform, I hereby r'en(h'that the .eIlpt)wm(were),oral"oted is ...undanre
7.is this a repair to on existing well: Yes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Connractian Standards sad thus a
If out is a repair,fill ant brown sell rarisim to i it fomwrimt acid explain the nature of cite capy of this rerord has bent provided to the.11 Dune,.
repair under#21 remarks session or on she bark of this Jams
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Tow]well depth below land surface: 200 (B-) 24s. For All Wells: Submit this fort within 30 days of completion of well
Fursrw0iplr nelhli,stm'Idepthsfdpv,vnt(esample-.i`000'and2C.1601 construction to the following:
10.Static water level below top of casing: 17 (R•) Division of Water Resources,Information Processing Unit.
Ifmm,,(eves it abave raring.use' 1617 Mall 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 wmpletion of well
I2.Well construction method: cunstructiun to the following:
(i e.auger,rotary.cable,duect push,etc)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
IJa.Yield(gpm) 6 Method of test: Air 24c.For Water Supply&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
I3b.Disinfection type: 70% HTH Amount: 12oZ completion of well consuucdon to the county health department of the county
where conswcted.
Fom,GW-1 North Carolina Depassomnt of Eavironnantai Quality-Division of Water Resources Revised 2.22-2016