GW1--05121_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO , DESCRIPTION
145 ft' 148 ft-
3002-A
184 ft- ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO I DIAMETER THICKNESS NI tTERIAL
0 ft. 114 et. 6 5/8 in. .188 Galv.Steel
Company Name
24-103 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Fk0ti1 C(1 DIAMETER THICKNESS b14 TERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) U. ft in.
3.Well Use(check well use): ft. ft in.
1Water Supply Well: R F SCREEN
FROM 'I0 DIAMETER SLOT SIM THICKNESS NI N'l Eltl t 1.
®Agricultural QMunicipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
°Industrial/Commercial DResidential Water Supply(shared) ig.GROUT
I1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n- 20+ ft- Bentonite Pour(96)50Ib Bags
QMonitoring DRecovery rt. ft.
Injection Well:
ft- ft-
0 Aquifer Recharge DGroundwater Remediation
—
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
\quifer Test
DStormwater Drainage rt.
Experimental Technology Subsidence Control ft_ ft.(Geothermal(Closed Loop) QTracer 20.MULLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
']Geothermal(Heating/Cooling Return: nOther(explain under#21 Remarks)
0 ft. 6 ft- Red Clay
4.Date Well(s)Completed: 6 3 24 Well ID# 6 rt. 16 it' Brown Clay
5a.Well Location: 16 ft- 95 ft- Brown Sandclav/Rock
Teleo LLC(Craig Miller) 95 ft. 104 rL Fractured/Loose Grafltte- _
Facility/Owner Name Facility ID#(if applicable) 104 fl- 200 ft' Granite , '4• � � r?
9311 Simpson Rd.Waxhaw 28173 Meadowbrook Lot#7 ft. ft- 4116
It. rt-
Physical Address,City,and Zip r'.
Union 05-078-012G 21.REMARKS
L'.',;: ..r.$
County Parcel Identification No.(PIN) .
*Transitioned casing to PVC at surface level
5b.Latitude and longitude in degrees/minutes/seconds or dechnal degrees: —
(if well field,one lat/long is sufficient) 22.Certification:
34.49.56 N 80.42.52 `,is
6-13-24
6.Is(are)the well(s)EaPermanent or DTenrporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the nyU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or gallo with ISA NCAC 02C.0100 or ISA 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 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: 200 (B-) 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 2@I00) construction to the following:
10.Static water level below top of casing: 18 (ft.) Division of Water Resources,Information Processing Unit,
1fwater 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) 22 Method of test: Air 24c.For Water SUDDIv&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: 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