GW1-2021-04536_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: TED
Frankie L.Oliver � � '`14.WATER ZONES:
Well Contractor Name FROM TO DESCRIPTION
3002-A ApR 2 9 2021 131 fe 145 ft E
e$II1t�Unl 176 ft. ft
NC Well Contractor Certification Number PrO��
��1iv1t-�'3t'tOn ��++ rtiQll d5."OUTER.CASING(for.multi•cased wells)OR LINER(if a' livable)'
Carolina Well Drilling D NR JQ" ' FROM t'. 1
O DIAMETER, THICKNESS MATERIAL
Company Name 0 16 ft' 6 14' t" 1 SDR21 PVC
21-84 I&INNER CASING OR'TUBING( eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER T MCKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft It. I in.
Water Supply Well: 47:SCREEN
FROM TO DIAMETER, 'SLOTSIZ.E THICKNESS MATERIAL
Agricultural [3MunicipaUPublic 0 ft. fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) -IS.GROUT
Irri ation FROM TO MATERIAL'. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ rt Bentonite Pour 20 501b Bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELPACR if a livable)
Aquifer Storage and RecoveryE3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
BGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F30ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock lye grain size,etc.)
0 ft. 32 ft' Red Clay/Dirt
4.Date Well(s)Completed: 3-29-2021 Well ID# 32 It. 106 ft. Brown Sandcla /Gravel
Sa.Well Location: 106 ft. 200 ft• Granite
Jackson Hargett ft ft.
Facility/Owner Name Facility TD#(if applicable) ft. ft.
5011 Lancaster Hwy. Waxhaw 28173 Southern Grove Lot#5 ft. ft.
Physical Address.City,and Zip ft. ft.
Union 04-255-003D 2I:.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:
34.54.171 N 80.36.867 W
4-15-2021
6.Is(are)the well(s) Permanent or Temporary Sig. e of Certified Well Contractor Date
By signing lhis.fonn,I hereby certify that the wells)was(were)constricted in accordance
7.Is this a repair to an existing well: [)Yes or WNo 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 weWdetails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page io 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 nndliple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 15 (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 Cei ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 22 Method of test: Air 24c.For Water SuDD►v &Iniection Wells: In addition to sending the form to
the address(es) above, also submit I.one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oZ completion of well construction to the county health department of the county
where constructed.
6
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources j Revised 2-22-2016
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