GW1-2022-07575_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRn'TION
Well Cun¢�actorNatne 3002-A 162 rt 167 ft
rf ft.
NC Well Contractor Certification Number 185 19745.OUTER CASING(for multi-cased wells)OR idNF.R(if a livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 rt. 126 It- 61/4! i SDR21 PVC
22-139 16.INNER CASING OR TUBING( eoth"ermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cunstruction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DTAMF.TF.R SLOTSI7.E THICKNESS MATERIAL
Agricultural [31dunicipal/Public it. ft- in.
Geothermal(Heating/Cooling Supply) Oftesidential Water Supply(single) n, ft in.
Industrial/Connnercial Residential Water Supply(shared) 18.GROUT
Irri atlon FROM TO MATERIAL EMI'LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rf 20+ ft' Bentonite Pour(25)501b Bags
Monitoring C3Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVE i.it'ACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERLAL FMPLACEMENT METHOD
Aquifer Test OStarmwater Drainage
ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG(attach additional sheets if necessary),
FROM TO DFSCRTPTION(color,hardness sotl/rock rain slze etc)
Geothermal(Heating/Cooling/Conlin Return) Other(explain under#21 Remarks
0 rf 3 rt' Red Clay
4.Date Well(s)Completed: 6-9-22 Well ID# 3 rt' 93 rt' Brown/Red Sandela
Sa.Well Location: 93 rf 115 rt• Brown;Sand/Gravel
Raymond Noonan 115 rt' 200 ft, Granite
Facility/Owner Name Facility ID#(if applicable) ft.
Southern Grove Lot#6 Waxhaw 28173 5013 Lancaster Hwy. �-
Physical Address,City,and Zip ft. ft. AUG
1 v 9f122
Union 04-255-003E 21.REMARKS F+ Lh
County Patrel Identification No.(PIN) J ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.55.201 N 80.36.178 W
6-20-22
6.Is(are)the well(s)OPermanent or OTemporary Sigmitre of CertifiedWell Contractor Date
By signing this form,I hereby verify that•the well(s)was(were)constructed in accordance
Lnv
7.Is this a repair to an eTdsting Well: Yes or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction,Standards and that a
If this&a repair,fill out known well construction infuriation and explain the nature of the copy of this record has been provided to the well newer.
repair ender#22 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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of wcl I
For multiple wells list all depths;(different(example-3@200'and 2gll)0� construction to the following:
10.Static water level below top of casing: 40 (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 Infection 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) 20 Method of test- Air 24c.For Water Supply&Iniectioni 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: 12oZ 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
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