GW1-2022-10586_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW-1) For Internal Us6 Only:
1.Well Contractor Information:
Frankie L.Oliver i�- Xgw�
FROM I TO I DIESCR1171ON
Well Cuatractor Name FROM
'1' 217
3002-A
249 '1' 32k 347
NC Well Contractor Certification Number A$CNG di lodiWi
Carolina Well Drilling FROM I TO J DIAMETER 711ICK1404S MATERIAL
Curnpatty Name 0 ft. I rt. In.1 75 1 6114 SDR21 PVC
&Call
2.Well Construction Permit#: 22-013 FROM TO U&METIER THICKNESS I MATERIAL
List all applicable wall construction prortits(i.e.UIC,County,State,Variance,etc.)
3.Well Use(check well use): n. ft.
ater Supply Well:
FROM I TO n7AMrrF.R SLOT SIM, I TMCKNWPAMS 11fATF.RTAi.
Agricultural 13Municipalftblic n ((L tn.
I Geothemial(Heating/Cooling Supply) JoResidential Water Supply(single) ft. in.
IndustriaVComrnercial ®Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT MMOD&AMOUNT
Non-Water Supply Well: 0 n 26+ ft* Bentoinire Pour(17)501b Bags
:)Monitoring [3Recovery
Injection Well:
ft.
3Aquifer Recharge [3Groundwater Remediation
Aquifer Storage and Recovery ®Salinity Barrier FROM TO X47MAL I RMPLACEMIEW17METH411)
Aquifer Test (3stormwater Drainage ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer
l
FROM TO I nrsCRTPTION(color,hardness,Mlhwk IM graln afte,etc.)Geothermal(Hearin Conlin Return) r3 Other(explain under#21 Remarks) 0 ft. 6� R. Brown wn Clay/Shale
4.Date Wells)Completed: 10-24-22 Well ID# 66 ft 375 1" Granite
ft. rt.
59.Well Location:
Dan Herlong ft. a.
FacilitylOwncr Name Facility 1D#(itapplicable) L.
Preserve @ Forest Creek Lot#51 Waxhaw 28173 te. n.
NOV 2 2 2022
Physical Address,City,and Zip ft. ft.
5 L L Z" 11
Union 05-117-082 -1U*1z?4AW 1,'f 267 P —
Cuunly Parcel Identification Nu.(PIN)
5b.Latitude and longitude In degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.455 N 80.45.005 W 11-10-22
6.Is(are)the well(s)JOPernmnent or [3Temporary NSignillw—c of I!Stifi.ed'Weli Contractor Date
By signing this fork I hereby certify that she well(s)was(were)constructed in accordanre
7.Is this a repair to an existing Well: ®Yes or Jallo with 15A NCAC 02C.0100 or 15A IVCAC 02C.0200 Well Consmiction Standards and that a
Ifilas&a repair,fill aut known well conctructimi informatinu arm]eAplain the nature of the copy of this record has heenpinvided to the well awner.
repair under#21 reinarb section or on the back of t1tisfann.
23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the sarne You may use the back of this page to provide additional well site devils 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; 375 (tt-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells tint all depths it'differeta(exionple-3@200'and 2@1001 construction to the following:
ID_Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
If vwtcr level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For liatectfoo Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also sub,nit one copy of this form within 30 days of completion of well
,cablc�direct push,etc.) construction to the following:
(i.e.auger,rotary
Division of Water Resources;Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 436 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(givin) 5 Method of test: Air 24c.For Water Suvyly At Injection Wells: In addition to sending the form to
the address(d) above also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 24o2 completion of Z11 construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Re-iources Revised 2-22-2016