GW1-2022-07564_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Tnfonnation:
Frankie L.Oliver VIVA t7A: s w
Well Contractor Name FROM TO DESCRHRYON
3002-A
116 rt. 143 n. R
�
215
NC Well Contractor Certification Number 15 (3CiTRR;G'S .G Pdr,Iiiilii-ea3ed'yells O1iiiNFlt IP;e Icaltlr'k`s c, +r` ,'<
Carolina Well Drilling FROM TO DIAMETER TMCKNE4S MATERLIL
Company Name 0 n' 48 6 114 t" SDR21 PVC
21-391 1dS?1NNE1ttCiti�`IN2°° lril UBINi; i4%theftnaliclo�ea 8b'
2.Well Construction Permit#: FROM I TO DIAMETER I 7MCKNFSS I MATERIAL.
List all applicable well cunsnnction permits(i.e.UX,Court,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. I n. In.
Water Supply Well:
FROM I TO I DIAMFTF.R SLOT SIZE I TMCKNRSS I MATF.RTAi
Agricultural ®MunicipaL?ubhc ft. ilL
Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) fL in
Industrial/Commercial ®Residential Water Supply(shared)
Irri ation FROM I TO MATERIAL E WLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 �' 20+ n' Bentonite Pour 22.5 501b Bags
Monitoring 13Reccrvcry ft. ft.
injection Well:
ft n.
Aquifer Recharge ®Groundwater Remediation .lo ,
19i•SAND/GRA
Aquifer Storage and Recovery ®Salinity Barrier FR/)M TO MATERIAL I EMPLAtEMffiNTMETH41D
Aquifer Test 13Stormwater Drainage M ft'
Experimental Technology ®Subsidence Control f►. tY.
Geothermal(Closed Loop) ®Tracer 7,77777ti.
PROM TO nFSCRTPTiON color,hardness sotl/twk t rain slae etc.
lGeothermal(Heating/CoolingReturn Other(explain under#l21 Remarks 0 ft. 8 ` ft. Red Clay
4.Date Well(s)Completed: 6-13-22 Well 1D# 8 ft' 40 n' Grey sandstone—,_ ? IV
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5a.Well Location: 40 ft. ft n' r "d �� -i
Francis&Patti Bums ft. n.
Y '
Facility/Owner Name Facility IDS(it applicable) ft. ft.
UM
Fairmont Dr.Carolina Carribean Lot#30 Waxhaw 28173 fc. n. ln#c-;srtQ,5on Prz%C0z=9
VBGWG
Physical Address,City,and Zip ft. `
Union 05-156-052 z1:'REMARfsc`' 'j
County Parcel IdentiLztion No.(PIN)
5b.Latitude and longitude In degreeshninutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
34.84.597 N 80.76.309 W
6-29-22
6.Is(are)the we➢(s)f3Pern►anent or Temporary Signature of C,atitiedlWell Connector Dam
Br signing this form!1 hereby certify tha,the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or tallo ,vith 15A NCAC 02C v0100 or 15A NCAC 02C.0200 Well Construction Standards and that u
if this&a repair,fill nut bumn well canrtructinn hiforntatirm and explain the nature njthr copy njthis record htir been provided to the well newer.
repair under 1l21 re,narks section or on the back of this form. 23.Site diagram t r additional well details:
8.For GcoprobetDPT or Closed-Loop Geothermal Wells having the same
You may use the back of this page to provide additional well site details or well
r
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL IN§TRUCTIONS
9.Total well depth below land surface: 300 (tt) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deptkv((different(ex<unple-3@J200'and 2@100D construction to the following:
10'Static water level helow top of casing: 54 (ft.) Division of Water Resources,Information Processing Unit,
if ureter level is above casing,use"+" 1611j Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For L ectlo 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 tbg 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) 6 Method of test: Air 24c.For Water Supply&Infection 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. 18oz completion of will construction to the county health department of the county
where constructer.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.1016
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