GW1-2022-09199_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14:WATER ZONES
FROM TO DESCRn'TION
Well Contractor Name
ft. ft.
3002-A
NC Well Contractor Certification Number 15.OUTER CASING(formulti•cased wells)OR LINER(if a livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERL4L
Company Name 0 ff 35 1" 1 61/4, in' SDR21 PVC
16.INNER CASING OR TUBING( eothertnal dosed-loop)
22-138
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.U1C,County,State,Variance,etc.)
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ,
FROM TO ry DTAMETER SLOT SIZE THICKNESS MAT F.RIAT.
Agricultural ®Municipal/Public ft. ft. in.
r Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) iu.
Industrial./Commercial E]Reaidential Water Supply(shared) 7,18.GROUT
_ Irrigation - FROM TO MATERIAL EMI'LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ «. Bentonite Pour(12)501b Bags
Monitoring Recovery
injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAW.1,PACK ff applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPL4,CEMENT METHOD
_ Aquifer Test [3Stonnwater Drainage
ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG(attach additional sheets ifnecessa
FROM To DFSCRTPTTON(color,hardness sell/rock rain sive etc)
_ Geothermal(Hearin Coolin Return) Other(explain under 421 Remarks
0 tt' 12 tt' Brown Sandcla
4.Date Well(s)Completed: 7-7-22 Well ID# 12 tt' 675 ft' Granite
5a.Well Location:
Robert M.McGirt ft. ft. Y - -� —_ ;�'
Facility/Owner Name Facility ID,#(if applicable) ft. «• S F P 3 n 2072
Ander Vincent Rd.Waxhaw 28173 ft. ft.
Physical Address,City,and ZipY Jz
Union 05-171-008 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.142 N 80.47.184 W
8-5-22
6.Is(are)the well(s)OPermanent or OTemporary Signature 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 existing well: E3Yes or ONo ivith 15A NCAC 02C.0100 or 75A idCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill our bump well construction infarmatinn and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#2I 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 wel I
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: 675 (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'wid 2(a)100� construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,itse"+' 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 met construction to the following:
(i.e.auger,rotary,cable,direct e u pushh,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) 0 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 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