GW1-2021-04532_Well Construction - GW1_20210429

r
RECORD GW-1 For Internal Use Only:
WELL CONSTRUCTION ( ) y
1.Well Contractor Information:
h
Frankie L.Oliver VWATER"C2NE$,' ...z. i
Well Contractor Name DESCRIPTION
3002-A REC1� 8
NC Well ContractorCeniricationNumber ING fofrtiulNcased*ells OR':LINV ifo"Heable Carolina Well Drilling APR 2 g 2021 DIAMETER ; THICKNESS MATERIAI.
Company Name n' 56 n 61/81 �D' SDR21 PVC
2.Well Construction Permit#: 21-45 JnTOnratlorl processing<) FROM R C TSo1NG'OR:Tu DIAMEIERtilrMa THICKNESS _. MATERIAI.
List all applicable well construction permits(i.e.UIC,County,Stat, ariance,etc.) fL fL In.
3.Well Use(check well use): ft. n In
Water Supply Well: �,17.kSCRREN, ,. ;xa .�;._. `• ��.. .�i; :::;, ..:� �. .. .-a .:3
FROM TO I DIAMETER SLOT SIZE, THICKNESS I MATERIAL
Agricultural 13Municipal/Public 0 n. ft. In.
Geothermal(Heating/Cooling Supply) BaResidential Water Supply(single) It. n, in.
IndustriaUCommercial 13Residential Water Supply(shared)
Itri ation FROM TO MATERIAL` EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n- 20+ fl Benton'ite Pour 33 501b Bags
Monitoring DRecovery ft. rL
Injection Well: n. n.
Aquifer Recharge Groundwater Remediation
FfL
rl Aquifer Storage and Recovery Salinity Barrier TO MATERIAI. FMPt ACF.MENTMETHOD
Aquifer Test [3StormwaterDrainage ft.
Experimental Technology Subsidence Control ft,Geothermal(Closed Loop) Tracer NG:LOG'attacGeothermal Heatin Conlin Return) Other ex lain under#21 Remarks TO DESCRIPTION color Inrdneu solUmek t In sire etc.)12 n' Fill Dirt/Cla4.Date Well(s)Completed: 3-26-2021 Well ID# 15 n' Brown!C /Rock
Sa.Well Location: 600 rLShane Fraser n
Facility/Owner Name Facility ID#(if applicable) n. n'
908 Chambwood Rd. Waxhaw 28173 ft. i.
Physical Address.City,and Zip ft. ft.
Union 06-030-014 ,21%,REMARV �
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.58.501 N 80.40.392 W
� 4-6-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or OTeroporary
By signing this form,1 hereby certify that the Kwll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3 Yes or oNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out luhown 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 hack of tls form.
23.Site diagram or additional wellidetails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page fo 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: 600 (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Iftinter 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
i
13a.Yield(gpm) 1.5 Method of test: Air 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit[ohe 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.
Fort GW-I North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2.22-2016