GW1-2021-04529_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14 WATER'Z0NE5
Well Contractor Name tl h FROM TO DESCRIPTION
3002-A 181 n• 408' IL I
NC Well Contractor Certification Number APR 2 9 2021 418 et. n
d5:'0.I)TE1t"CASilyG'fbr iiiultl•casedwVells.UR%INER,Ifd"`Iicable' ,.
Carolina Well Drilling le n Processing Uni FROM TO DIAMETER THICKNESS MATERIAL
rfiBln�� 0 n- 123 n 61/8" I"' SDR21 PVC
Company Name DW w
R Seon
21-07 1br INNER'GASING`OR'TUBING `' herhial'closed loa ,
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERAAi
List all applicable aell construction permits(i.e.111C,County,State,Variance,etc.) ff. ft. I r In.
3.Well Use(check well use): ft. rt. In.
^47cSCREEN..... ;: t.r
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL+
Agricultural 13Municipal/Public 0 ft. ft. �•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R• ft.
Industrial/Commercial [3Residential Water Supply I (shared)
a8;iGROUT '
lrri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R' 20+ n' Bentonite Pour 12 501b Bags
Monitoring pRecovery ft. It.
Nection Well: ft
Aquifer Recharge 13Groundwaler Remediation
",q9-SAND/GRAv1tL'PACK Ito li hie
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERiAI. EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage rt. ft.
Experimental Technology Subsidence Control n• R•
Geothermal(Closed Loop) Tracer f..20 DRILLING<ILOG'attach 4dditlonel heets9rnecessar '<<s ;:r .
FROM TO DESCRIPTION color,hardness soll/roek t In size etc.
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks)
0 M' 13 n Fill Dirt/Cla
4.Date Well(s)Completed: 3-17-2021 �y��i 13 n' 19 n Red la
sa.well Location:
19 r�. 28 n
Charlotte Grace One Church 28 rt' 60 Brown Sandcla
Facility/Owner Name Facility lD#(if applicable) 60 n' 112 O Sandstone
2609 Chestnut Ln.Matthews 28104 112 rL 425 rL Granite
rL ff.
Physical Address,City,and Zip
Union
07-141-001D :21;:RENIARKS ;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/rninutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
35.30.706 N 80.43.203 W 4-6-2021
6.Is(are)the well(s)oPetmanent or E3Temporery
Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the i ll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or QNo with 15A 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 fire 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-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: 425 (ft-) 24a. For All Wells: Submit this,!form within 30 days of completion of well
For nudtiple wells list all depths if different(example-3®200'and 2@100) construction to the following:
10.Static water level below top of casing: 13 (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 (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) 60 Method of test: Air 24c.For Water Sunoly &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: 28oZ 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
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