GW1-2022-07574_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver 14.WATER ZONES
Well Contractor Name FROM TO UESCHII'TION
89 fl. 198 [l. 6
3002-A ,
207 r`' 465 r`' 482
NC Well Contractor Certification Number 15.OUTER CASING(For multi-cased wells)OR iINF.R(if a licable
Carolina Well Drilling FROM TtlI DIAMETER THICKNESS MATERUL
Company Name
0 r`' 58 ft. 6 1/4! '.n' SDR21 PVC
22-72 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well constniction permits(i.e.UIC,County,State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): et. [t. in.
17.SCREEN
Water Supply Well: FROM TO nTAMfITR SLOT SUR THICKNESS MATERTAL
Agricultural ®MunicipaUPublic fL fL in.
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single)
ft. ft. in.
Indusirial/Cotmnercial [3Residcn6a)Water Supply(shared)
18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ rt. Bentonite Pour(21)501b Bags
Monitoring ®Recovery
injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVE ,PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3St0rmwater Drainage ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG(attach additiohal':sheets if necessa )
Geothermal(Hearing/Cooling Return) 0 Other(explain under#21 Remarks) FROM I TO DFSCRTPTTON color,hardness sotlhock type,grain sire etc)
0 r` 26 r`' Brown'Clay
4.Date Wells)Completed: 6-8-22 Well ID# 26 rt' 45 r`' Brown/Blue Slate
5a.Well Location: 45 r`' 500 n' Blue V 'Sate to E CI]
" LELD
James B. Fincher ft. ft. 9` ,f
Facility/Owner Name Facility ID#(if applicable) ft.
i
5003 Old Highway Rd.Waxhaw 28173 ft. ft.
Physical Address,City,and Zip ft. ft. IfItC4 Fri
t?7,
Union 04-285-015D 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
34.52.503 N 80.37.468 W
_ 6-20-22
6.Is(are)the well(s)OPermanent or OTemporary a of Certified Well Contractor Date
By signing this form,1 hereby certify ihai',ihe well(s)was(were)constructed in accordance
7.Is this a repair to an eldsting well: ®Yes or Jallo with 15A NCAC 02C.0100 or 75A AiCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out knrnvn 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 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: 500 (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
Fm multiple wells lict all depihs ifdifferent(er imple•3@l200'and 2g1001 construction to the following:
10.Static water level below top of casing: 34 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 246.For Nection 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 cable,
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) 22 Method of test: Air 24c.For Water Supply&Iniection6 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: 30oZ 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