GW1-2022-05581_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver 14.WATER ZONES _
Well Contractor Name FROM TO DESCRn'TION
260 ft• 384
3002-A 497 ft' 507 ft'
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR I.iNF.R(if a lieable)'
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERLAL
0 ft. 62 ft, 61/4 t"' SDR21 PVC
Company Name
22-154 16.INNER CASING OR TUBING,(geothermal dosed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well consttztciion permits(i.e.UIC,Couniv,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. t"•
17.SCREEN
i"Irrigation
ater Supply Well:PP Ye FROM TO DIAMETER SLOT Sr7E THICKNESS MATF.RTAi,
Agricultural []MunicipaliPublic ft. ft.
Geothermal(Heating/Cooling Supply) ©i Residential Water Supply(single) ft. it. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(17)501b Bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
-19.SAND/GRAVF.i,PACK 0f a Ircable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Storn[water Drainage
Ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOGstattach additional sheets if necessa )
FROM TO DFSCRTPTION(color,hardness sell/rock type,grain size etc)
Geothermal(Heatin /C ohng Return) rJ Other(explain under*21 Remarks)
0 ft. 9 et. grown Clay
4.Date Well(s)Completed: 5-20-22 Well ID# 9 ft. 55 ft' Brown Rock
5a.Well Location: 55 ft. 525 f' Granite
Allen&Teresa Terwilliger ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' ft. 5`+B — .._
2826 Crane Rd.Waxhaw 28173 Woodhall Lot#3 ft. ft.
Physical Address,City,and Zip ft. ft.
Union 06-207-087A 21.REMARKS On ro'cown 'Un s
VO IOG
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.58.263 N 80.47.528 `l �
6-4-22
6.Islam)the well(s)faPermanent or Oj Temporary 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: ElYes or JRNo with 15A IVCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our ksto n ivell coratnu tion information and explain the nature of the copy of this record has been provided to the well namer.
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: 525 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welLc list all depths if di,Qerem(eicample-3( 200'and 2gl00� construction to the following:
10.Static water level below top of casing: 25 (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) 15 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: 30oz 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