GW1-2022-05577_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L. Oliver '441-:WATER ZONES
Well Contractor Name FROM 110 DESCRUITION
3002-A 56,59 ff 65,73
80 109 ft. 137 144 192
NC Well Contractor Certification Number , ,150,158,163,
15.OUTER CASING(for multi-cased,iVells)O LINER(iftipjiS r_B_ 2��.
THICKNESS Carolina Well Drilling FROM TO DIAMETER s M
Company Narric 0 53 " 1 6 114 SDR21 PVC
46.INNER CAMKC-OR TUBING,JA6therifial closed-too
2.Well Construction Permit#: 21-279 FROM TO DIAMETER THICKNESS MATERIA I L
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) in.
3.Well Use(check well use): ft. n. in.
Water Supply Well: 17.S C R E F N
FROM TO mAMETTIR, 81.OTST7.FI TfnCKNFSS MATT.RTAL
:.3Agricultural r]Municipal/Public ft. ft. in.
7,'IGeothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in.
:]Industrial/Cominercial [3Residential Water Supply A&GROUT",
Ohligation FROM TO MATERIAL EMI-LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20+ ft* Bento I nite Pour(18)501b Bags
Monitoring [3Recovery ft. ft.
Injection Well: ft. ft.
able
Aquifer Recharge Groundwater Remediation 19. )SAND/GRAVELYACK(if a' tic
Aquifer Storage and Recovery 13saunityBarrier FROM TO MATERIAL EMPL.4 CEMENT METHOD
Aquifer Test [3storinwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 30.DRILLING LOG(attach additional sheeisifneiessarV
Geothermal(lieating/Cooling Return) nOther(explain under#21 R,..Jkr) FROM TO DFSCRTPTION(color,hardness,sallfrock type,grain size
0 ft. 12 ft, Brown Sandclay
4.Date Well(s)Completed: 5-9-22 Well ID# 12 ft- 200 ft' Granite
5a.Well Location: ft.
Mario Sbardella ft. ft.I RECIRV
Facility/Owner Name Facility ID#(if applicable) ft. ft.
400 Smokey Hollow Dr.Waxhaw 28173 Marvin Creek#90 ft. ft. jUN 1. 4. zuzz
Physical Address,City,and Zip ft. rt.
'
Union 06-222-159 21.REMARK&
County Parml Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tathong is sufficient) 22.Certification:
35.05.137 N 80.48.559 W C_ 6-4-22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well- [3Yes or ONo with 15A VCAC 02C.0100 or 75A NICAt 02C.0200 Well Construction Standards and that a
Ifihis is a repair,fill out knoiviz well construction iqformatinn and explain the nature of the copy of this record hav been provided in the well owner.
repair tinder#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; 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Foi-multiple iveliv list all depthv if different(example-3@)200'and 2gl()OP construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use­+" 1617 Mail Service C'enter,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.) g:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of test: Air 24c.For Water Supply&Iniecth m 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: 1202 completion of well construction to the county health department of the county
where constructed.
Fin in GW-I North Carolina Department of Environmental Quality-Division of Water Resource.; Revised 2-22-2016