GW1--04456_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver .14.WATER ZONES
Well Contractor Name FROM TO 1 DESCRIPTION
I
3002-A 48,96 ft' 132 ft'
183 ft' 224 it 273
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased`lvells)OR LINER(if ap licable) '
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 43 ft' 61/4 . in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).. . -. .
2.Well Construction Permit#: 23-52 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN - - - " • `.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic ft. it. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft rt. i,,,
Industrial/Commercial OResidential Water Supply(shared) 15.GROUT i
Irrigation . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(15)50Ib Bags
Monitoring ®Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation 19.'SAND/GRAVEi,PACK(if applicable) •
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPL ACEMENT METHOD____
Aquifer Test 0Stormwater Drainage
ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) $Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilhoek type,grain sine,etc.)
0 ft' 6 ft- Brown Clay
4.Date Well(s)Completed: 6-27-23 Well ID# 6 ft. 15 ft. Brown Rock
5a.Well Location: 15 ft' 300 ft' Granite _
Louis 0 Berke!Trust.... ft, ft. g. p_'J Y .%.�f, J
Facility/Owner Name Facility IDf1(if applicable) ft. ft. ......... "'
Old Waxhaw Monroe Rd.Monroe 28112 Lot#3 ft. ft. JUL Z Q ZU23
Physical Address,City,and Ft. it.
In^,i 7i'::1al,^."1 (r:.r sties a.^1 i!r•:.
Union 09-414-026H 21:REMARKS r at;r e �,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: — - -
(if well field,one lot/long is sufficient) 22.Certification:
34.56.511 N 80.38.186 W
7-3-23
Temporary Signature of Certified Well Contractor Dace
6.Is(are)the well(s)MPermanent or
By signing this farm,I hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: II Yes or IONo with 15.4 NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out lawn 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 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 surface: 300 tit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-44200'and 1(g1100') construction to the following:
10.Static water level below top of casing: 12 _ (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) 13 .. 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 deparunent of the county
where constructed. I
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016