GW1--05109_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name mom TO DESCRIPTION
164 ft. 170 rt.
3002-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mull-cased wens)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER IIIICK\ESS \I,TF RI II.
0 ft. 157 rt. 61/4 in' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
23-333
FROM
2.Well Construction Permit# FROM 'CO DIAMETER THICKNESS hL',TERL4L
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM 10 DIAMETER SLOT SIZE 1HICK ESN M uTERI\I.
:agricultural DMunicipal/Public ft. ft. ill.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it. in.
DIndustrial/Commercial DResidential Water Supply(shared) le GROUT
DIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fc. 20+ Bentonite Pour(77)50Ib Bags
°Monitoring ()Recovery ft. rt.
Injection Well: ft. ft.
Aquifer Recharge ()GroundwaterRemediationD ly.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test DStormwater Drainage ft. R.
Experimental Technology Subsidence Control ft. ft.
(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION tcolor,hardness,soil/ruck type,grain.iize,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarirs)
0 ft" 6 ft- Red Dirt
4.Date Well(s)Completed: 6-10-24 Well ID0 6 ft. 25 it. Brown Clay/Shale
5a.Well Location: 25 it 150 ft• Brown Sand/Gravel
Vadim Kozlyuk 150 ft. 180 IL Granite ^ -
t'
Facility/Owner Name Facility ID#(if applicable) fl it �,
8016 Harpers Grove Rd.Waxhaw 28173 Oldstone Forest#23 ft. ft. AUG
2 7 2074
Physical Address,City,and Zip Ft F[
Union 05-063-091 21.REMARKS
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:
34.90.944 N 80.72.031 W
6-18-24
6.Is(are)the well(s)10Pernanent or ()Temporary Signature of Certified Well Contractor 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 EINo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,,fill out bowl 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 1 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: 180 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
For naltiple well,list all depths if different(example-3(a 200'and 2@Io0') construction to the following:
10.Static water level below top of casing: 29 (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 i in.i 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) 50 Method of test: Air 24c.For Water Suuuly&infection 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 to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016