GW1-2022-05582_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
r
ran le L.Olver
34.,,WATER ZONES,
Well Contractor Naine FROM TO DESCRIPTION
51 ft. 76 ft.
3002-A
274 rc. n.
NC Well Contractor Certification Number 15„OUTER CASING(.for multi-cased Jells)OR idNF.R(if,n `ieable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 fi' 37 ft' 61/4 in' SDR21 PVC
21-419 16.7NNER CASING,OR TUBING.( eothei•inal closed-ioo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UX,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER SLOT SIZE TFrFCKNF.SS MATF.RTAL -
Agricultural [DMunicipal/Public rL f'L in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Cormnercial Residential Water Supply(shared) IS:GROUT
Irrigation FROM TO MATERIAL EMI'I.ACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20+ ft. Bentonite Pour(18)501b Bags
Monitoring _ Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEi.PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPI 4CEMENT METHOD
Aquifer Test [3Stnrmwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG(attach addition`a1'sheets if necessa );:
FROM TO DFSCRTPTTON(color,hardness sotl/rock rain size etc)
Geothermal(Hearin Coolie Return) Other(explain under 421 Remazks)
0 ft. 9 ft' Red Dirt
4.Date Well(s)Completed: 5-13-22 Well ID# 9 n. 30 Brown Dirt
5a.Well Location: 30 ft. 300 fi' Granite
Emma McCullough ft. ft. a
Facility/Owner Name Facility ID#(if applicable) ft.
2634 Crane Rd.Waxhaw 28173 ft. er. 2022
ft.
Physical Address,City,and Zip ft. lf}$8r , �
Union 06-207-001 C %21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one Ian/long is sufficient) 22.Certification:
34.58.800 N 80.48.352 W
- 64-22
6.Is(are)the well(s)OPermanent or OTemporary azure of Certified Well Contractor Date
By signing This farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an e:dsting well: ®Yes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this u a repair,fill out brown ivell construction infrnmation and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this farm.
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: 300 (ft-) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple welly list all depthv if different(etuunple-3(o)200'and 2gl00) construction to the following:
10.Static water level below top of casing: 38 (ft.) Division of Water Resources,Information Processing Unit,
I(walcr level is above casiR,r;,rise"+" 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,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) 40 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subunit 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 2-22-2016