GW1-2022-03712_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver
Well Contractor Name FROM TO DESCRIPTION
123 n' 132 ft'
3002-A 144 f` 153 j n' 157161
NC Well Contractor Certification Number a 1Sr UTER A 81-N:d s torinalti cow, ells,OR`tiINER'(Irs'"Iieable) ,;,
Carolina Well Drilling ni
TO ' DIAMETER THICKNFSS MATERIAL
Company Name 1171 R 61/4" I"' SDR21 PVC
21-186 ;16:INN1 R=Cd iIN OR TUBING eattierinal closed 106 ._
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft- fL 1"'
3.Well Use(check well use): R' t1 1n
Water Supply Well: .�.I N '.L
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. h in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it in.
Industrial/Commercial Residential Water Supply(shared)
Ii ri alion FROM TO ! i MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n' 20+I ft' Bentonite Pour 22 501b Bags
Monitoring Recovery fL ft.
Injection Well: ft ft
Aquifer Recharge 13Groundwater Remediation
t:,19:3ANDlGRAY1) PAQK if a '11cAb1A ,.
Aquifer Storage and Recovery Salinity Barrier FROM TO I I MATERIAL I EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control rt• n.
i
Geothermal(Closed Loop) Tracer .20iDRIELiNG'I30x`Attach d8ftl8nai; hegtl tf fieiessg`
FROM TO ' DESCRIPTION(color,hardness soittrock t rain sire etc.) k
Geothermal(Hearin /Conlin Return) Other(explain under#21 Remarks)
0 M 12' n' Red Clay
4.Date Well(s)Completed: 1-27-2022 Well ID# 12 rt' 87' n' Brown Sandcla
5a.Well Location:
87 ft. 10'6 rl B w a a`t l-G
Cochran&Tanner Properties 106 ft- 206 B' Granite
elily/Owner Name Facility lD##(ifapplicable) R' n'
10429 Lancaster Hwy. Waxhaw 28173 Wildwood Place Lot#2 ft. n f „
Physical Address.City.and Zip 3 t"Union 05-104-035M z1::REMAR �,, "
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one larAong is sufficient) 22.Certification:
34.49.531 N 80.43.596 M
2-16-2022
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certiftald Well Contractor Date
By signing ihir.form, I hereby certify that Are vtwll(s)%us(were)constnicted 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 infomtation and explain the nalure of the copy of this record has been provided to the well owner.
repair tender#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-I 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 nndtiple trells list all depths if different(example-3 n 200'and 1@1001 construction to the following:
10.Static water level below top of casing: 23 Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1017 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: 1436 Mail Service Center,Raleigh,NC 27699.1636
)3a.Yield(gpm) 15 Method of test: Air 24c.For Water Supply&I iectihn 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 the 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