GW1-2022-05578_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver 14.WATER ZONES
FROM TO DESCRH',TION
Well Cuntractor Naine
127 ft• 147 ft.
3002-A 156 ft' 163 ft' 189,273
NC Well Contractor Certification Number lj.OUTER CASING(for inulti-cased'wells)OR LiNF.R(ifa tieable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERUL
Company Name 0 ft. 122 It' 61/4 in' I SDR21 PVC
21-313 16.INNER CASING OR TUBING( eothertnal closed-loo )`_,
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) R in.
.Industrial/Conexcial Residential Water Supply(shared) l8.GROUT
.)Industrial/Commercial
_ Irrigation FROM TO MATERIAL EMI'LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ n Bentonite Pour(27)501b Bags
Monitoritrg CIRecovery
injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVF.T,PACK(if a livable `
Aquifer Storage and Recovery [3Satinity Barrier FROM TO MATERIAL FMPI_4CEMENT METHOD
Aquifer Test E)Stormwater Drainage
ft. ft.
Experimental Technology OSubsiderice Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG lattach additional sheets if necessary)
Geothermal(Hearing/Cooling Return) Other(ex lain under 4121 Remarks) FROM To DFSCRTPTTON color,hardness soilhock tyM grain shtx etc.)
0 ft. 8 ft, Yellow Clay
4.Date Well(s)Completed: 54-22 Well ID# 8 fc. 100 ft. Brown/Blue Rock&Gravel
5a.Well Location: 100 ft. 500 rt. Granit t:— E i
Sims Road of Union LLC Preserve @Forest Creek#12
ft. ft.
Facility/Owner Name Facility ID#i(if applicable) it. ft. jUN 1 4 2022
4013 Waxhaw Crossing Dr.Waxhaw 28173 ft. n. zC
Physical Address,City,and Zip ft. rt. 'WJQ/i80G
Union 05-117-067 21.REMARKS
County Pafccl Idcatification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.330 N 80.45.306 W
- (a7 6-4-22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
Br signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or RNo with 15A NCAC 02C.0100 or 15A NCA'C 02C.0200 Well Construction Standards and that a
if this if a repair,fill out known ivell 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 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 lift all depthv if different(e unple-3@200'and 2(a7100� construction to the following:
10.Static water level below top of casing: 26 (ft.) Division of Water Resources,Iltformation Processing Unit,
If water level is above casing,ttse"+" 1617 Mail 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 fonn within 30 days of completion of well
(i.e.auger,rotary,cable,direcct 12.Well construction mu construction to the following:
t p pushh,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 636
13a.Yield(gpm) 3 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.
Forrn GW-I North Carolina Department of Environmental Quality-Division of Wafer Resources' Revised 2-22-2016