GW1-2021-04534_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver '44.WATER ZONES°-
Well Contractor Name FROM TO DESCRIPTION
114 f° 120 ft-
3002-A V ��'
''��✓✓ ft. ft.
NC Well Contractor Certification Number !15.,OUTER'CASING;(for multi-cased wells)bR LINER(if a" licable)
Carolina Well Drilling ApR 2 9 2021 FROM TO DIAMETER THICKNESS MATERIAL,
Company Name AID cacg�li� I{I 0 ft. 110 ff 61/87' I"' SDR21 PVC
2.Well Construction Permit#: 20-590,U1G(I1:3t10U FROM
CT SO OR T DIAMETERh¢rmaITHI closed-loop)
MATERIAL
AWR SedC)"
List all applicable well construction permits(i.e.UIC,County,Wdfi,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLOT SIZE. THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. It. in. 1
Geothermal(Heating/Cooling Supply) 5aResldential Water Supply(single) It. fL in, j
Industrial/Commercial 13Residential Water Supply(shared) 1g,GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ fL Bentonite Pour 30 501b Bags
Monitoring Recovery ft. ft.
Injection Well: ft ft.Aquifer Recharge Groundwater Remediation 19;SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer r20.DRILLING LOG(attach additional sheets if necessar
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin sirs,etc.)
0 f° 32 ft* Brown:Clay/Shale
4.Date Well(s)Completed: 4-2-2021 Well ID# 32 ft' 70 ft• Soft Blue Slate
5a.Well Location: 70 ft 95 1" Brown!Rock/Shale
Joshua Fairbaugh 95 It' 200 ft' Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1617 Turtlewood Dr. Waxhaw 28173 Lot#42 ft. ft.
Physical Address,City,and Zip IL M
Union 06-054-155 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:
34.58.139 N 80.41.167 W
4-15-2021
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, I hereby certify that;the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JoNo 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 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 I 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 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') COtISt[UC[ion to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
If water level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this;fonn 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
i
13a.Yield(gpm) 40 Method of test: Air 24c.For Water Supply&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 t6 ejcounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016