GW1-2021-04196_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well Contractor Information:
Frankie L.Oliver VWNIMWell Contractor Name TO DESCRIPTION
3002-A139 ft-
ft.
NC Well Contractor Certification NumberCarolina Well Drilling TO DIAMETER THICKNESS MATERIAL
0 fL 110 n. 61/8 1n' SDR21 PVC
Company Name �"1G" NER-iCASIN(s UR Ti1BINCr' etltlierma1 clo3ed rod `..
2.Well Construction Permit#: 20-111 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permitr(i.e.UIC,County,Stale,Variance,etc.) f't• ft. in
3.Well Use(check well use): ft. n. in.
Water Supply Well: r 17i00kEEN j . , r'. =-. 1,?`, .. [f',
FROM TO DIAMETER SLOT SITE THICKNESS MATERIA►,
Agricultural [3MunicipaUPublic 0 n. ft. In
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. ln.
lndusttial/Commercial E3Residential Water Supply(shared) S�l8;fkilU .,xs ass 1.;- ,; �•�,, ;-
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD lr AMOUNT
Non-Water Supply Well: 0 n 20+ H• Bentonite Pour 12 501b Bags
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
.�14'ShNDICRi�VEt.`.litlC•K-ifta i licali a., e ..-,:< ,.. � � :; .�� .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
ExperimentalTechnology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20:j1)R111stNG'1(3G:ettaah:addltloriai sheets'iftiekessar ,,
Geothermal(Heatiti Coolin Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soll/rock type rain size etc.)
0 n' 21 n' Red Clay
4.Date Well(s)Completed: 3-10-2021 Well ED# 21 II 99 n' Bro n'Sand/Gravel
5a.Well Location: 99 ft. 200 rL Granite
Tanner Design&Build n. ft.
Facility/Owner Name Facility IDN(if applicable) n• it' v�
6951 Huey Rd.Waxhaw 28173 Wildwood Place Lot#5 ft•
Physical Address.City,and Zip R' 2021
Union 05-104-035G 721 UPWi k—s7,77. �:>
. n,rn�$Illfj�-1rS11
County Parcel Identification No.(PIN) °
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rt( a'0j;o 3
(if well field,one latAong is sufficient) 22.Certification:
34.49.361 N 80.43.392 W
3-23-2021
6.Is(are)the well(s)OP rmanent or 13TemporarySig o of Certified Well Contractor Date
By signing this form, I hereby certify that the mills)arts(were)consinicted in accordance
7.Is this a repair to an existing well: [3Yes or WNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a
If this is a repair,ff11 out known well construction information and explain lire nature of the copy of this record has been provided to the well omier.
repair raider#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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mukiple wells lint all depths if diQ'erem(example-3Q200'and 2Q100') 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 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 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) 10 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%HTH Amount: 120Z completion of well construction tolthe county health department of the county
where constructed.
Fomt GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I