GW1-2023-01790_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.1vA 2ONItS
FROM TO UESCKII'TION
Well Contractor Name 96 D' 105 f
3002-A
110 f`' 203 f' 221 254 291 323 398 437 463 500 523
NC Well Contractor Certification Number
Carolina Well Drilling FROM To DIAMETER THICKNt vS MATERIAL
0 ft' 81 ft' 61/4 I"' SDR21 PVC
Company Na,ne 1116INf1l6R
2.Well Construction Permit ft: 22-415 FROM To I DIAMETER I THICKNESS I MATERIAL
List all applicable rvell cunsnuction permits(i.e.UIC,Cuunly,Slate,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 7 CIt EN
FROM To DIAMETER St.OT SIZE THTCKNFSS MATFRIAL
Agricultural ©Municipal/Public ft. rt. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt f4 In.
Industrial/Cominercial �Reaidential Water Supply(shared) ilia
GRM
Inri ation FROM TO MAWAUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(22)501b Bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge (3 Crroundwater Remediation 19. A A .PACK i e
Aquifer Storage and Recovery [3Sh1inity Barrier FROM TO MATERIAL EMPLACEMENT MEMOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology [3Subsidcnce Control n. ft.
Geothermal(Closed Loop) OTracer 20.DULLING
Geothemial (Heating/Cooling Return) Other ex lain under#21 Remarks FROM TO nfSCRTPTION color,hardneW seflhoek tylmpe,grain axe atc l
0 ft. 6 f' Red Clay
4.Date Well(s)Completed: 12-21-22 Well ID# 6 it' 37 n' Brown Clay
5a.Well Location: 37 ft. 72 ft.
Town of Waxhaw 72 ft' 600 f' Granite
Facility/Owner Name Facility 1DM(it applicable) n. n'
301 Givens St.Waxhaw 28173 ft. r— 9 `
Physical Address,City,and Zip ft. ft.
Union 05-115-026 Z1
Cow,ty Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/miuutes/seconds or decimal degrees:
(if well field,one Lit/long is sufficient) 22.Certification:
34.55.219 N 80.44.423 W C53,7—'E,.�f�j
1-19-23
6.Is(are)the well(s)Wermanent or Temporary Signature of Certified Well Contractor Date
By signing this farm.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or Jallo with 15A VCAC 02C.0)00 ur 15A NCAC 01C.0200 Well Construction Standards and that a
If this if a repair,fill ow bunt+r well cnnstructinn information anal explain the nature of the copy of this rerord has been provided to the well owner.
repair tinder#21 remarb section or on the back of this form.
23.Site diagram or additional well details:
S.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.Tustal well depth below land surface: 600 Ifs.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fen multiple welLs lift all depthf if d(8erenr(ex<onple-3@4200'and 2(g)001 construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For l lection 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.auget,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) 17 Method of test: Air 24c.For Water SuDDIv & 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: 36oZ completion of well construction to the county health department of the county
where constructed.
Fo,m GW-I North Carolina Department of Environmental Quality-Division of Water Resource.; Revised 2-77-?016