GW1-2022-07571_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor information:
t
Frankie L. Oliver 1a.wATER,zoIv15
Well Contractor Name FROM TO DESCRH-TION
49,61,ft' 90,99 ft.
3002-A 103 ft' 167 ff 172187198
NC Well Contractor Certification Number ,15.OUTFR'CASiNG(for,multi-caseit Sells)0 LTNFR(ifa livable)
Carolina Well Drilling FROM TO DIAMETER THICICNS;S MATERIAL
0 ff 45 fl' 61/4 'n' SDR21 PVC
Company Name 16.INNER CASING OR TUBING( eothermal closed-too '
2.Well Construction Permit#: 21-341 FROM TO DIAMETER THICKNESS MATERUL
List all applicable well eonstilection petmtits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRTCANESS MATFRTAL
Agricultural [:]Municipal/Public ft. ft. in.
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
3
Industrial/Cornmercial E3Raaidential Water Supply(shared)
18..GROUT
-Irrigation FROM TO MATERIAL EMI-LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et' 20+ ft. Bentonite Pour(27)501b Bags
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge ®Groundwater Remediation 19,SAND/GRAVEL PACK(tf licatile) `
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATFYaAr EMFLAC-EMENT METHOD �
_ Aquifer Test DStonnwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCRIPTION(color,hardness solUrock rain sire etc)
Geothermal(Hearin /Coolie Return) Other(explain under#21 Remarks)
0 fl' 6 ft' Red Clay
4.Date Well(s)Completed: 6-6-22 Well ID# 6 fL 25 It- Brown Dirt/Rock
5a.Well Location: 25 ft. 225 ft' Granite - .-•
Tanner Design&Build, LLC ft. ft. - V t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Wildwood Place Lot#10 Waxhaw 28173 ft. ft.
Physical Address,City,anJ Zip FL ft. IfT 'fSftt? t):1 q�f�.Y o-7S Urgi
Union 05-104-035X y21.REMARKS ,�,.,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lax/long is sufficient) 22.Certification:
34.49.432 N 80.43.387 W
7-5-22
6.Islam)the well(s) Permanent or 13Temporary Signature of Certified Well Contractor Date
k 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 Jallo with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill nut known well consruction information and explain the nature of the copy of this record has been provided to 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-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: 225 (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(etumple-3g200'and 2(a11001 construction to the following:
10.Static water level below top of casing: 48 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,else"+" 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 fonn 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) 35 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: 15oZ 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