GW1-2022-10585_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14:lyATERq n C`y3 t t Py. a 'F`a ' r. s x Cyr,°;,
FROM TO ' DESCHH'TION
Well Contractor Narme
138 ec. 147
3002-A
158 407, ec' 491 707
NC Well Contractor Certification Number 13 OL?7SPRt51NCr([oitiiultl?°casrr8113:Ulf*ill 1t<Ifa'a"j`
Carolina Well Drilling FROM I To DIAMETER TMCKNLvs MATERIAL
0 ec' 51 n' 61/4 In' SDR21 PVC
Company Name k10.1 `sCsA:i7 NOJOR I'1'U$INGi A tA Mn`111,0 a til-io1, i<s&4;_. ' ak
2.Well Construction Permit#: 22-166 FROM TO' DIAMETER THICKNESS MATERLU.
List all applicable well constnicilon permits(i.e.U1C,Cowtty,State,Variance,tic.) ft. et. in.
3.Well Use(check well use): [t. n. In.
cal C3RFi8N ak .. '` arse a .,; �xa .rr4A Cz. c 't4 n
WalerSupply Well: FROM I TO mAMFTM SLOTSI7F I THICRNF•SS I MATF.RTAI,
Agricultural ®Municipat/Public it. n to i
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) iL R in.
IndustriallCommercial 131kesidential Water Supply(shared) oR" RO - '. ,✓-; ry g Y t a ,:*
ri_ ei iaua
Irrigation FROM TO I MATERIAL EAM ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ec• 20+ n Bentonire Pour(23)501b Bags
Monitoring 13Recovery n. ft.
Injection Well: n; ft.
Aquifer Recharge ®Groundwater Remediation
��.�$"Nt)/("s1tA`cY�`5�,!`I�YOK� [t9 111` 't` -iv:"a•,.a�ts �2 .;., a -, a,�c Ky V 'a
lAquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMFIrr METHOD
Aquifer Test [3Storrmwater Drainage n
Experimental Technology ®Subsidence Control n• n•
Geothermal(Closed Loop) ®Tracer 20 D1tII,LIN. (1t;ax1fiiltilillalil Etf i3i Y ' 7 .
Geothermal(Heating/CoolingReturn) Other(explain under 421 Remarks FROM I To nFSCRTPTtON color,huanes,m 4lh,"k tyM titsin sliv,etc
0 ec• 16 [c' Red Clay
4.Date Well(s)Completed: 10-21-22 Well ID# 10 et' 34 n' Brown Dirt
Sa.Well Location: 34 ft' 41 n' --arown Rock
William Hartong 41 n 750 ec' Granite f
Facility/Owner Name Facility ID#(it applicable) [t. n. a 'i,' 'SV i;_ °
Preserve @ Forest Creek Lot#33 Waxhaw 28173 et• ft.
Physical Address,City,and Zip
05-117-042 z1 :RFMs+1RSfi+ � r'
Union O
JuLl
County Parcel Ideatification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
34.54,256 N 80.44.952 W e ::� c 11-10-22
6.Is(are)the well(s)JOPermanent or Temporary Signature
gnacaeof Certified Well Contractor Date
By signing this forth.1 hereby certify that the well(s)ins(were)comirucled in accordance
7.Is this a repair to an eidsting well; ®Yes or &jNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Consmtction Standards and that a
if this is a repair,fill ow uumv well crmsrruction itiforrnation and explain the rarure of the copy of this reenrd has been provided to the well oxmer.
repair tinder#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: SUgMMAL
9.Total well depth below land surface: 750 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple iveliv list all depths(f&ferew(exmntile-3@J200'and 1( ]W1 Construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Wormation Processing Unit,
if inter lcvcl is above casing,ase"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Weed on Wells: In addition to sending the form to the address in 24a
Air Rotary above, also subrhit 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 Resourcesi Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1436 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2.5 Method of test: Air 24c.For Water Supply&Inieection 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: 44oz completion of well construction�to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourc)CA Revised 2-22.2016
i