GW1-2022-09201_Well Construction - GW1_20220930

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver ftffif''&. = R> 3 ; s
Well Cu¢trat:[ur Name
FROM TO'. I DESCRUniON
113 .it. 119
3002-A n' j
136 ft• 146 n' 155 169`195
NC Well Contractor Certifica[ionNumber '(O 'fF.ft `S1NG r_ it•e'fill�il:� elt55 13'1a1N11:i `'tfi�` 'ttile�"
Carolina Well Drilling FROM ro: DIAMETER TI1CRaqE8s MATERIAL
0 fl' 1Q6 n' 61/4 In' SDR21 PVC
Company Name L, y _z ..
20-447 b;31VNiL+11 :.,+Olt .; CrY e"t1i ";rL+lt'B'e'11-16" �,s;
2.Well Construction Pernmit41: FROM TO DIAMETER I TMCKNFSS I MATERIAL,
List all applicable well cunsnt+ctwn permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): EFROM
ft. In.
Water Supply Well: TO i WAMM, ,R SLOT ST7F THTCKNFSS MATFRTAT.
Agricultural ®Municipal/Public n in.
Geothermal(Heating/Cooling Supply) §aResidential Water Supply(single) n. in.
htdustrial/Comm eicial ®Residential Water Supply(shared) tjtj
Irrigation TO MATF,UAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weli: 0 ft. 20+ n' Bentonite Pour 16 501b Bags
Monitoring 13Recovery ft. ft.
injection Well:
Aquifer Recharge ®Groundwater Remediation
a�uS`.�7))/(rR.'• tiif'AC1C .t tiTatit � 3;r� ,r^� `•i-,si � �,
Aquifer Storage and Recovery 13Sdhnity Barrier FROM I To MATERIAL I EMPLAi EMENT METHOD
Aquifer Test ®Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracerzo; RttiutN: OG"afi6'Ehirdiiliinatsfi9€islfii2aea3 _ s n�,+_", ?;
Geothermal (Heating/Cooling Return) Other(explain under*21 Remarks FROM TO nrSCRTPTTON color,hardness soft/rock type,praln stre etc
0 ft. 6 ft, Brown Dirt
4.Date Well(s)Completed: 8-24-22 Well ID# 6 ft. 64 n' Brown!Sandcla
So.Well Location: 64 ft. 96 it- Bt W k
Craig Miller 96 n' 1 225 n' Granite
Facility/Owner Name Facility LL3W(if applicable) [t. n. r, 3 k 5 r fi
6923 McCaslan Ln.Waxhaw 28173
Physical Address,City,and Zip ft. ft. —• _
-;2VRE1N [,;:gyp t� 3°r s` k •�1 °
Union 05-096-036
County Parcel ldentifitaatiunNo.(PIN)
Sb.Latitude and longitude in degrees/ndnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.52.278 N 80.43.492 W
8-31-22
6.Is(are)the well(s)SPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certt/y thai the well(f)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Jallo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consmtction Standards and that a
If this is a repair,fill(Pitt bvnrn well construction itlf(Prmarinn and explain the nature t f the copy of this record hat 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 satne. You may use the back of this page to provide additional well site details or well
construction,only 1 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 tend surface: 225 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For n dltiple wells list all depths if diQ'erett(extimple-3@200'and 2@100) construction to the following:
10.Static water level below top of cashrg: 46 (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 fulecoon Wells: In addition to sending the form to the address in 24a
Air Rotary above,also subunit 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) 14 Method of test: Air 24a For Water Supply&jWection 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: 15oZ completion of well construction to the county health department of the county
where constructed.
Foam GW-I North Carolina Department of Environmental Quality-Division of Water Resource.,? Revised 2-22-2016