GW1-2021-04200_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 1a: ATER ZONES..
Well Contractor Name FROM TO DESCRIPTION
89 n' 143 fL P
3002-A
372 n' ft.
NC Well Contractor Certification Number 0StOUTER1CAS1NG.foi tnulti-cased:(dells'OR'LINER IPs" Iiceble
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 A. 58 n' 61/8", I"' SDR21 PVC
20-534 °:I�INNER•CASING:ORT WG; eotbeimalclosedltrii"' ::. . . :•'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) n- ft. In.
3,Well Use(check well use): ft. ft. in.
Water Supply Well: >i7:'SCREEN,
pP y FROM I TO I DIAMETER I SLOTS= I THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 fL fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. )„
Industrial/Commercial 1311esidential Water Supply(shared) '18.'GROUT,
lrri ation PROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 t' 20+ ft' Bentonite Pour 58.5 501b Bags
Monitoring DRecovery t. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
`.l9iSANU/GRAV.IrI.zP 'CIC.fP6 Ilculile t ``
Aquifer Storage and Recovery 13Sali.ity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer :10.I)RILLING G,ettachiaddldbhil:bheets•IP-neCM iyY
FROM TO - DESCRIPTION(color,hardness soll/rock l• In size etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks)
0 't. 3 ft, Red Clay
4.Date Well(s)Completed: 12-11-2020 Well 1I# 3 n' 45 n' Brown Sand
Sa.Well Location: 45 H' 50 n
. Brown Rock
Larry Allen 50 n' 1 400 n' Granite
Facility/Owner Name Facility ID#(if applicable) ft' n'
Tn
9204 Maggie Robinson Rd.Waxhaw 28173 ft. ft.
Physical Address,City,and Zip ft. ft.
Union 05-186-001N 21. S BEMARK ,.. '.
County Parcel Identification No.(PIN)
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5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.50.111 N 80.47.536 W
" 1-4-2021
6.Is(are)the well(s)MPermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this farm, I hereby certify that the twil(s)uws(were)corsinscled in accordance
7.Is this a repair to an existing well: ®Yes or QNo 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.
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repair under k21 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: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: 24 (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 Inlection 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) 8 Method of test• Air 24c.For Water Suauly&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: 24oz completion of well construction to the county health department of the county
where constructed.
Fort GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016
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