GW1--04453_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver .14.WATER ZONES, . . ,
FROM TO DESCRIPTION
Well Contractor Name '
3002-A 74,811t• 112 ft.
172 ft' 188 IL 230,241
NC Well Contractor Certification Number 15,OUTER CASING(for multi•casedl wells);OR LINER'(if all livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 56 ft' 6 1/4 in' SDR21 .PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop) - ,
21-352
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. It. ID.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) it. ft. in.
lndustrial/Cominercial Residential Water Supply(shared) u t t
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ It: Bentonite Pour(13)50Ib Bags
Monitoring ®Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation 49.SAND/GRAVF.i PACK(if applicable) '
Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stonmwater Drainage
ft. ft.
Experimental Technology E3Subsidence Control ft. ft. .
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) n Other(explain under 4#21 Remarks)
0 ft' 12 ft' Red Clay
4.Date Well(s)Completed: 3-9-23 Well ID# 12 If 50 ft' Brown Sand
5a.Well Location: 50 It' 300 ft' Granite
Mark Webster ft. ft. -- y= - a
Facility/Owner Name Facility IIl#(if applicable) ft. ft. ` "' ""
7817 Rillwood Dr.Waxhaw 28173 ft. ft. JIJI 1 0 'U1Z3
Physical Address,City,and Zip ft. ft. i + ivDr rr" 1{�r•`�
Union 05-156-028 21.REMARKSs . tl ;`.
-.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.84.695 N 80.76.696 W
• 62 t 4-7-23
6.Is(are)the well(s)MPermanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or EiNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction information and 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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(gi200'and 2(arg100') construction to the following:
10.Static water level below top of casing: 38 (ft.) 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,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 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: 18oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016