GW1-2023-00716_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver .14.WATER ZONES
FROM TO DESCRII'TION
Well Contractor Name
185 et' 280 ft'
3002-A
327 ft. 372 rt. 408,427,446
NC Well Contractor Certification Number 15.0UTRR CASING(far multi-cased wells)OR LINFR(if n 'livable)
Carolina Vllell Drilling t` FROM TO DIAMETER THICKNESS DIATERL4L
�A� 1 ZQ23 0 rt. 70 ft. 61/4 in. SDR21 PVC
Company Name
tr.
22-391 - - ^�•`"'1'�t�C C'}�"'''�;1 l��`'$ 16.INNER CASING OR TUBINf,( euthermal closed-too ) '
2.Well Construction Permit# lfli0s`.'�'rs tT,) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coumy,State,Variance,etc.) rt. ft.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM I TO DIAMI=,,R SLOT SIZE THICKNFSS MATERIAL
Agricultural []MunicipabWblic ft. ft. in.
Geothermal(Heating/Cooling Supply) RResidentiaI Water Supply{single) fL ft- in
Industrial/Cormnercial OResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: .0 et. 20+ rc. Bentonite Pour(15)501b Bags
Monitoring Recovery It. ft.
injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation 19.SAND/GRAVF.T,PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERVL EMPLACEMENT METHOD
Aquifer-Test Stonnwater Drainage ft. ft.
£xperimetnai'T echnoiogy .""Subsidence Control ft.
Geothermal(Closed Loop) Tracer '20:DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCRTPTION(color,hardness soli/rock t rain size etc)
Geothermal(Heating/Cooling/Conlin Return) i Other(explain under#21 Remarks)
0 ft. 5 ft, Red Clay
4.Date Well(s)Completed: 12-7-22 Well ID# 5 ft• 47 fl' Brown Sandcla
5a.Well Location: 47 ft' 60 It. Granite/Quartz Mix
Kenneth&Demetrick Chambers 60 ft' 460 ft. Granite
Facility/Owner Name Facility lD#(if applicable) ft. ft.
8909 Quail Roost Dr.Waxhaw 28173 Triple C Mini Ranches#50 ft. ft.
Physical Address,City,and Zip
ft. I ft.
Union 05-153-017A 21:REMARISS_ J.
County ParcelIdentdicetion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lathoug is sufficient) 22.Certification:
34.85.965 N 80.76.947 W
1-3-23
6.Is(are)the well(s)Wermanent or OTernporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)consirucled in accordance
7.Is this a repair to an wasting well: []Yes or RJNo with 15A NCAC 02C.0100 or 15A ArC4C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out bunco well conuntction information arm]explain the nature of the copy of this record has been provided to the well owner.
repair under##21 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 well
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 snriace: 460 (ii-) 24a. For All Wells: Submit this form within 30 days of completion of wel l
For multiple wells lia all depths if differs¢(example-3L200'aul 2@700n construction to the following:
10.Static water level below top of casing: 34 (fL) 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 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 method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undergroun&Injection Control Program,
FOR WATER 91 TPPLY WELLS TIC ONLY: t636P.Ra::Se ^a Ccntcr,:P.al;,ieh,P;C 2?69^:635
13a.Yield(gpm) 2 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: 28oz completion of well construction to the county health department of the county
where constructed. j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016