GW1-2021-04535_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES:
Well Contractor Name IV1.. FROM TO DESCRIPTION
3002-A p 70,86 et' 92
NC Well Contractor Certification Number 9 Z0Ji 108 ft 126 ff, 181
5.OUTER CASING(for multi-cased wells)OR LINER if a 'livable
Carolina Well Drilling �cS1C1�Pr
U ROM TO DIAMETER THICKNESS MATERIAL
Company Name B v 0t10 0 ft. 45 eL 6 14' 1n' SDR21 PVC
20-615 6NR$0 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#' EFROM
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: N -;
TO DIAMETER .SLOT SIZE THICKNESS MATERIAAgricultural []Municipal/Public ft. in.Geothermal(Heating/Cooling Supply) Residential Water Supply(single) IL in.
Industrial/Commercial Residential Water Supply(shared) T
Irri ation TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft. Bentorite Pour 7.5 501b Bags
Monitoring Recovery ft. ft.
Injection Well:
ft. It.
Aquifer Recharge OGroundwater Remediation
'19."SAND/GRAVEL-PACK(if applicable).
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional•sheets if necessary)"
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPI[ON(color,hardness,soil/rock type,grain sin,etc.)
0 ft. 14 fl• Brown Cla
4.Date Well(s)Completed: 3-22-2021 Well ID# 14 fL 34 ft' Brown'Shale/Rock
5a.Well Location: 34 ft. 300 ft. Blue Slate
Tanner Design&Build ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7407 Lancaster Hwy.Waxhaw 28173 Wildwood Reserves#30 ft. ft.
Physical Address.City,and Zip ft. fL
Union 05-020-001 zL REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laMong is sufficient) 22.Certification:
34.52.400 N 80.39.572 W
4-15-2021
6.Is(are)the well(s)oPermanent or ,Temporary Signature of Certified Well Contractor Date
By signing this fonn, 1 hereby certify that the nvell(s)was(were)constnucted in accordance
7.Is this a repair to an existing well: OYes or RNo with 15A NCAC 02C.0100 or 15A NCACO2C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction infonnation and explain the nature of the copy of this record has been provided to the well ouvter.
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 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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nndtiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 5 (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 Iniection 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) 4 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: 18oZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20I6
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