GW1-2022-05586_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14.WATER ZONES ' -
FROM TO DESCIEWPON
Well Contractor Natne
47 ft' 122 ft.
3002-A
210 et. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased Wells)OR i,iNFR{1!it licable)
Carolina Well Drilling FROM TO DIAMETER T THICKNESS MATERIAL
Company Name 0.INNER CASING OR`TUBING(/4 In. SDR21 PVC
Ft ft.
21-312 otherinal closed-lot
2.Well Construction Permit# FROM To DIAMETER THICKNESS MATEALAL
List all applicable well construction permits(i.e.UIC,Cuunty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
17.SCREEN
Water Supply Well: FROM I TO I DTAMRTE.R; SLOT STU, TRTCKNFSS MATF.RTAI.
Agricultural [3Municipal/Pubhc ft• ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft.
Industrial/Cominercial Residential Water Supply(shared) 18!GROUT
_]Irrigation FROM TO MATERIAL ENWLACENWIT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentohite Pour(12)501b Bags
Monitoring 13Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVF.T.PACK Of applic able)
Aquifer Storage and Recovery []Salinity Barrier FROM TO NUTERUL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage
ft. ft.
Experimental Technology [I Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary).
J Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DFSCRTPTTON(color,hardness soiltrock type,grain size etc)
0 ft' 17 ft, Brown Clay/Shale
4.Date Well(s)Completed: 5-17-22 Well ID# 17 ft' 29 ft. Brown Rock
Sa.Well Location: 29 ft. 300 ft' Blue e
John Toscano ft. ft. E
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8509 Potters Rd. South Waxhaw 28173 ft. ft. -
Physical Address,City,and Zip Ft. ft. jrfofirauosn PrO'1;oezing Unk
Union 04-347-011 21.REMAMI;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wilting is sufficient) 22.Certification:
34.82.970 N 80.65.580 W `
6-10-22
6.Islam)the well(s)taPerntanent or OTemporary Signature of Certified Well Contractor Date
k,signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or allo with 15A 1VCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out knit well cotisrraclirnt information and explain the nature of the cnpy of this recnrd has keen provided to the well owner.
repair under#21 remarks section or an 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-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 multiple ivells list all depths if different(example-3(a,)200'and 2gll)0� construction to the following:
10.Static water level below top of casing: 31 (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 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 2769 9-1 636
13a.Yield(gpm) 1.5 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 fonn 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.
Forrn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016