GW1-2021-04201_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver .Y4:'WATER.ZONES>..... ;.;'• :'z
FROM TO DESCRIPTION
Well Contractor Name
143 rt' 156 ft. j
3002-A ft ft.
221
NC Well Contractor Certification Number t 1S.OUTER-.CASINC.':fdr.multl-eAk6d:`ells):OR INNER lEa 'licatile
Carolina Well Drilling FROM TO DIAMETER TTiICKNPSS MATERIAL
Company Name 0 n 131 rL 6 1/8" I"' SDR21 PVC
INNER CASING.OR TUBING( ei tli rmel closed loo
2.Well Construction Permit#: 20-110 FROM TO DIAMETER T MCKNFSS MATERIAI.
List all applicable will construction permits(i.e.UIC,County,State,Variance,etc.) rL ft. In
3.Well Use(check well use): rL ft. In.
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic 0 ft. rL In.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) rL In.
Industrial/Commercial DResidential Water Supply(shared)
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f4 20+ ft' Bentonite Pour 10 501t)Ba s
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 1313roundwater Remediation
SAND/CGRAY$L°PACK tr;e tice6le 'r
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATFRiAL EMPLACEMENT METHOD
Aquifer Test 13StormwaterDr'ainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer €,2&DRILLING,WG:ittacti,additioi at tiaets.if necessa
Geothermal(Heatin ooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sollfrock type,grain size etc.
0 ft. 17 ft. Red day
4.Date Well(s)Completed: 3-12-2021 Well ID# 17 rt' 118 ft. Bow Sand/Grave
5a.Well Location: 118 ft. 300 ft- Granite
Tanner Design&Build ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6953 Huey Rd.Waxhaw 28173 Wildwood Place Lot#6 rL ft.
Physical Address.City.and Zip ft. ft.
P
Union 05-104035E zrREMARKs , �." ..T
County Parcel Identification No.(PIN) t
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: Ir 1forr:3tion proceSSing Unit
SeC34.50.100 N 80.44.208 `,ir ; Li 3-23'•on
-23-2021
6.Ware)the well(s)mPermanent or 13Temporary Signature of Certified Well Contractor Date
By signing ibis fonn,I hereby certify that the er/l(s)was(were)conshraated in accordance
7.Is this a repair to an existing well: 13Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiruction Standards and that a
If this is a repair,fill out brown well construction itlforination and etylain fire nature of the copy of this record has been provided to Ilie well tanner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobeffiff 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-I 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 00 24a. For All Wells: Submit this,fotm within 30 days of completion of well
For nndtiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 23 (ft.) Division of Water Resources,Information Processing Unit,
If ivater level is above caring,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: 6 (in.) 24b.For Infection 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) 4 Method of test- Air 24c.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 18oZ completion of well construction to 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