GW1-2022-05587_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 DESCRIPTION
146 1" 149 fL
3002-A eL fL370
NC Well Contractor Certification Number
aIS.OUTER CASING for niilti-casedwells)'OR LfNEIt,ifs' linable .,
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fr 136 ft- 61/4, 1" SDR21 PVC
21-55 ,'1'6 INNER CASING OR T URING giotbetmal"closed-1
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Slate,Variance,etc.) f6 ft. in
3.Well Use(check well use): ft. ft, in.
Water Supply Well: FROM TO DIAMETER� SLOT S17.E I THICKNESS- MATERIAL
Agricultural []Municipal/Public ft. fL In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial [3Residential Water Supply(shared)
_1S:':GROUT
hri ation FROM TO MATERIAL J EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ fL Bentonite Pour 26 501b Bags
Monitoring DRecovery ft. fl.
Injection Well:
Aquifer Recharge Groundwater Remediation D fL
Aquifer Storage and Recovery Salini Barrier F9'SAND/GRAYELrPACK MATERIAL
D _
9 g rY � tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StotmwaterDrainage ft. ft.
Experimental Technology 13Subsidenec Control ft. ft.
Geothermal(Closed Loop) OTracer -'20`DRILLING.LOG(itti6,additiotiel sheets if riecessar a
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soft/mck tin size etc.)
0 ft. 18 ft. Red Clay
4.Date Well(s)Completed:4-27-2022 Well ID# 18 '- 75 ft
Brown Clay/Rock
Sa.Well Location: 75 ft. 400 fL Granite
Sims Road of Union, LLC 5019 Waxhaw Crossing ft. ft.
Facility/Owner Name Facility ID#1(if applicable) n- ft. C I
Preserve @ Forest Creek Lot#26 Waxhaw 28173 ft. ft.
Physical Address.City,and Zip
ft. ft. JUN TZ122,
Union 05-117-035 '21" MA '
County Parcel Identification No.(PIN) i '.r g t)rif
arnw s1 r i '
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.253 N 80.44.594
5-4-2022
6.Is(are)the wells) Permanent 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: E]Yes or Jallo 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 the nurture of the copy of this record hms been provided to the well owner.
repair under#21 remarks section or on the back of this jonn.
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 1 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: 400 M-)
For mulliple wells list all depths if different(example-3@200'and 2@1001 con For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 34 (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Air Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Sunuiv &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: 24o2 completion of well construction to':the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016