GW1-2022-03714_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 34.WATER°ZONES,
t�
FROM TO DESCRIPTION
Well Contractor Name
ft. ( ft.
3002-A 19-7 et. I ft. 2, f
NC Well Contractor Certification Number 15:`OUTER CASING_(fof ritalti-cased;wells)OR-T INER if a' licable). •,`
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 115 ft' 6 1/4" '"' SDR21 PVC
-'16ANNER CASING O11 TUBING "e(ithermal closed-loop) �
2.Well Construction Permit#: 21-183 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply 1 Well: 'i FROMREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public et. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) in.
Industrial/Commercial OResidential Water Supply(shared) A18:GROUT„m...,.
Irrigation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour 12 501b Bags
Monitoring DRecovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19:'SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:-DRILLING;COG(attach addit onal sheets if necessar '
FROM TO DESCRIPTION(color,hardness sod/rock type, ram size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 16 ft, Red Clay
4.Date Well(s)Completed: 1-24-2022 Well ID# 16 ft' 80 ft' Brown,Sandcla
5a.Well Location: 80 ft. 105 ft' Brown!Sand/Gravel
Cochran&Tanner Properties 105 ft' 250 ft. Granite
Facility/Owner Name Facility rD#(if applicable) ft. ft.
10419 Lancaster Hwy. Waxhaw 28173 Wildwood Place Lot#7 et. ft. t n^ T-
Physical Address.City,and Zip ft. ft.
Union 05-104-035E 21.REMARKS,,,.,, 5"°
2-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lao9ong is sufficient) 22.Certification:
34.49.638 N 80.43.669 W
��-� 2-2-2022
6.Is(are)the well(s)&Permanent or DTemporary Signature of Cerr�Well ontmctor Date
By signing this fonn, I hereby certify that the wells)was(x•ere)constnated 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 wellldetails:
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: 250 (ft-) 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') construction to the following:
10.Static water level below top of casing: 33 Division of Water Resources,Information Processing Unit,
1(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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,duect 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) 10 Method of test: Air 24c.For Water Supply&Injection 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: 15oZ completion of well construction to`the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016