GW1--02225_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
!
Frankie L.Oliver Z14.WATER•.ZONES.. ' :.',--i' ,. :.: > _"
FROM TO DESCRIPTION
Well Contractor Name
3002-A 98 ft- 118 ft- I'
139 ft" 146 ft' 168
NC Well Contractor Certification Number '
l5.OUTElECASING(for nitiki eased wells)uOR.LINER'(if•applicable)
Carolina Well Drilling FROM TO DIAMETER! THICKNESS MATERIAL
0 ft. 94 ft' 61/4 in' SDR21 PVC
Company Name "16sINNERCASING'OR TUBING.(g iothernial'closed-loop) `
2.Well Construction Permit#: 23-124 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. f[ in
3.Well Use(check well use): ft f[. in.
REE
Water Supply Well: FROM TO DIAMETER. SLOT
SLOT SIZE THICKNESS MATERIAL�,.
Agricultural OMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) MI Residential Water Supply(single) ft. ft. int
Industrial/Commercial DResidential Water Supply(shared) Yti GROUT.. „V,"..,. ;( :x• ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ et- Bentonite Pour(15)50Ib Bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. rt.
Aquifer Recharge I0Groundwater Remediation ''
=19:'SAND/GRAVEL TACK.(if'applicable) ' ' '`'2 ,
Aquifer Storage and Recovery le Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. rt. i
Experimental Technology OSubsidence Control ft. et. i
Geothermal(Closed Loop) DiTracer ''20.1)RILLING LOGIattach additioiiiil sheets if necessary), `; .,
Geothermal(Heating/Cooling Return) ',Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillreck type grain size etc.)
0 ft' 16 ft- Red Clay
4.Date Well(s)Completed: 1-30-24 Well ID# 16 f`' 82 ft Brown Clay/Sand
5a.Well Location: 82 ft. 200 ft. Granite _
Carl Nichols ft. rt !'.k. .,•o..Q�. 'iac a , ;, .
rt. ft. q
Facility/Owner Name Facility ID#(if applicable) A r(�R V$ LG L7
�
10402 New Town Rd.Waxhaw 28173 et. et.
Physical Address,City,and Zip rt. ft. Inf.r it ;::•' ;l?r-�: 'R,•,:?j uFhi
21 REMARKS.`ii:; it-y „•...Larr,l.,vr.),Jl. . .7w . ,.
Union 06-240-002B °• •-
i
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:
•
34.99.517 N 80.82.753 W _c_::::: ;:". . 2-7-24
6.Is(are)the well(s)MPennanent or OTemporary Signature of Certified Well Contractor is Date
By signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or j!jiNo with/5A NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided tb 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
II
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1Q100) construction to the following:
10.Static water level below top of casing: 28 (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 adilition 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 21 Method of test: Air 24c.For Water Supply &Tnie iti In 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: _ 12oZ completion of well construction Ito 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