GW1-2022-09574_Well Construction - GW1_20221021

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WELL CONSTRUCTION RECORD (GW-1) For Internal Useortly:
1.Well Contractor infonnation: 1
Frankie L.Oliver ra11'ATER2() i ti;e 7T 4'f y
[FROM
ROM TO DESCRIPTION
Well Contractor Name
3002-A 14 '1' 118 n' �
64 ft. 171 ft. 190 i
NC Well Contractor Certification Number SLjffpR CAA tf9 lPiitllil"fellg?OR'itlhll�,R i�'`"
Carolina Well Drilling TO I I DIAMETER TIUCiCNUiS MATERLkL
fErt.
2 iV Olt. I6 1r� In. SDR21 PVC
Company Nntne m. da
2.Well Construction Permit#: 22-330 O DIAMETER TRICiUMS MATERIAL
List all applicablewell cunsnuction permits(i.e.UIC,County State,Variance•etc.) fL iu.3.Well Use(check well use): rL in.
ater Supply Well: I �niAMF:TF.R StOTS17.F TATCKNIISS MATFRiAi
Agricultural ®MunicipaUPublic fL In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it, in.
IndustriaVCominercial ®Residential Water Supply(shared)In•1 ation TO MATERIAL EMPLACENCENT METHOD&AMOUNT
Non-Water Supply Well: tt.
Monitoring Recovery [t. [t.
injection Well: ft. ft.
Aquifer Recharge ®GroundwaterRemediation
;19'�i1ND/(iitA� T7�'.CK�fi (tc e y;• `�' � trt _ :zT �� �>.;_
IAquifer Storage and Recovery ®Salinity Barrier FROM TO I I MATERIAL EMP[AtFMFN1 Mt rHtro
Aquifer Teat [3Stnrmwate4•Drainage ft. ft.
Experimental Technology Subsidence Control n• n•
Geothermal(Closed Loop) ®Tracer s0 R `1i71v. G attBcli'"ddNlotttit fs:tflietessa L c
GLothttmal eadn /Coolie Return) Other(explain under 4121 Remarks FROM TO I I nFSCRTPTiON color,hardness sotl/rock type,itraln sloe etc
80 n' 200 ft' Granite
4.Date Well(s)Completed: 9-22-22 Well ID#
59.Well Location:
Teleo,LLC ft, n.
Facility/Owner Name Facility 11M(it applicable) ft. ft.
9322 Richardson King Rd.Waxhaw 28173 Kings Gate Lot#1
Physical Address,City,and Zip Pt nrsQll
Union
05-171-006 211ti1A1DGC"+; .d
County Parcel Identifimtiun No.(PIN)
"Drilled exis ng 80'well deeper to a depth of 200'
Sb.Latitude and►ongitude in degreeshninutrslseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.129 N 80.46.540 W 9-26-22
6.Is(are)the well(s)OPermanent or Temporary Signature of C 'red Well Contractor Date
By signing this font.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: taYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
if dtit&a repair,fill out known even conttructimt inf(,mwtinn ura1 explain the ruuure of the copy of Chit 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 Geothermal Wells having the same You may use t}le back of this page to provide additional well site details or well
construction,only I GW-i 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 well
For multiple well,liti all depths if different(e anitnie-3&700'and 2@1001 construction to the following:
10.Static water level below top of castug: 23 (fL) Dlvis I fon of Water Resources,Information Processing Unit,
1/wnter level is above casing•use-" 1 17 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For cc on Wells: In addition to sending the form to the address in 24a
Air Rotary above, also su mit 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
13s.Yield(gpm) 15 Method of test: Air 24c.For Wa r Supply&Iniection Wells: In addition to sending the form to
the address(es I above, also submit one copy of this form within 30 days of
13h.Disinfection type: 70%HTH Amount: 12oZ completion of well construction to the county health department of the county
where cons tru hIeed.
Form GW-I North Carolina Department of Environmental Quality-DivL4ion of Water Rwourcei Revised 2-22-2016