GW1-2021-06786_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver "•t14r;WATER20NES r G {: ?.° 6'> `;
.FROM TO DESCRIPTION
Well Contractor Name
83 it' 241 rL
3002A
367 n 431 n 461
NC Well Contractor Certification Number 1S'(1t17 ER LASING.foe ndlti eav 4'ella•OR 11NBR' e "Itrxtble Fi `
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 fL 37 n' 61/8 i" SDR21 PVC
Company Name 7 1NNER'CASItVf3`,OR T.UB1iVG Ctitberfnel'Moseb loL yi
2.Well Construction Permit#: 21-100 FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: "l7°S�CREEN
Pp y FROM I TO I DIAMETER I SLOTSWE I THICKNESS I MATERIAL
JNo
gricultural ®Municipal/Public ft. ft. in,
eothermal(Heating/Cooling Supply) Residential Water Supply(single) n- n, in.
ndustrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO .�, MATERIAL EMPLACEMENT METHOD&AMOUNT;
n•Water Supply Well: 0 n. 37 Bentonite Pour 17 501b Ba s
Monitoring Recovery ft. ft.
ection Well: ft. ft.
quifer Recharge Groundwater Remediation
quifer Storage and Recovery [3Saliniry Bar ier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test DStormwater Drainage n• n'
xperimental Technology Subsidence Control n• n•
eothermal(Closed Loop) Tracer ,eothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness sol0rock t rain size etc.
0 7 ft- Red/Brown Clay
4.Date Well(s)Completed: 5-27-2021 Well ID# 7 « 28 tL Brown IDirt/Rock
58.Well Location: 28 n 500 f" - Granite
Michael Monday
Facility/Owner Name Facility ID#(if applicable)
t1. fL 'P"
9106 Woodhall Lake Dr.Waxhaw 28173 Woodhall Lot#13 ft. ft. ) -------------------------------
Physical Address.City.and Zip fL ft. y n, 451Ct
Union 06207474 c21 REMARKS i1y+ e
'V
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
34.59.24 N 80.48.10 W
e::�<12 6/18/2021
6.Is(are)the well(s)gPermanent or 13Temporory St ature of Certified Well Contractor Date
By signing this form,1 hereby certify that the we/l(s)nns(acre)constructed in accordance
7.Is this a repair to an existing well: 13Yes or WNo 01h 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction it formation 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 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: 500 (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 2@1001 construction to the following:
10.Static water level below top of casing: 37 (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,duaa 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) 8 Method of test: Air 24c.For Water Supply&Iniection 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: 30oZ 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