GW1--05116_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
WellContractorName FROM TO DEN CWPTNJN
220 f`. 246 et.
3002-A
287 ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERI AI.
Company Name 0 et. 195 et. 6 5/8 in' .188 Galv. Steel
23-369 16.INNER CASING OR TUBING(geotherm al dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS A ATEIRLAL
List all applicable wwll construction permits(i.e.U1C,County,State,Variance,etc.) et. et. In.
3.Well Use(check well use): et ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS NI II I:It1:tI.
DAgricultural 0Municipal/Public ft. rt. tn.
▪Geothermal(Heating/Cooling Supply) laResidential Water Supply(single) et. ft in.
❑Industrial/Commercial DResidential Water Supply(shared) 111.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD!r AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft* Bentonite Pour(37)50lb Bags
MonitoringRecovery ft. ft.
Injection Well: ft. It.
-Aquifer Recharge �GroundwaterRemediation 19.SAND/GRAVEL PACK lit applicable)
Aquifer Storage and RecoverySalinity Barrier FROM TO bf.-1TERL L EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage It. It.
Experimental Technology Subsidence Control ft.. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION'color,hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks 1
0 ft 6 ft Red Clay
4.Date Well(s)Completed: 6-26-24 Well ID# 6 rt. 185 rt. Brown Clav/Sand/Gravel
5a.Well Location: 185 ft* 300 ft* Granite
Tanner Design&Build rt. rt
Facility/Owner Name Facility ID#(if applicable) ft. ft. ``-- t.. +, • ti ``
1008 Martha's Meadow Ln.Waxhaw 28173 Martha's Meadow#2 ft. ft. AUG 2
CGT4
ft. ft.
Physical Address,City,and Zip
Union 04-306-009F 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or dedmal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.89.092 N 80.63.515 `,i,
7-5-24
6.Is(are)the well(s)aPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this.form, 1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or DNo with 1SA NCAC 02C.0100 or 15A 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 to the well owner.
repair under#21 remarks section or on the back a f 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: 300 (ft-) 24a. For 411 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3 00'and 2Q100') construction to the following:
10.Static water level below top of casing: 24 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mall 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 24e.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: 1 8oz 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