GW1-2022-08506_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
49 et. 97 fe.
3002-A
357 rr. 363 rt.
NC Well Contractor Certification Number 15.OUTER CASING:(for multi-cased wells)OR LINER(if a licable
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 eG 45 n' 6 1/4" '"' SDR21 PVC
22-45 `16.INNER CASING OR TUBING(geothermal closed-loop)
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): f[. ft. in.
17.SCREEN
Water Supply Well: "K
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. i"•
Industrial/Commercial [3Residential Water Supply(shared) 'IS.GROUT
IITI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 e[. 20+ et. Bentonite Pour(28)501b Bags
Monitoring EIRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
°19:SANDlGRAVEL PACK(if applicable),
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer TestStormwater Drainage
Experimental Technology [@Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)i
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 rr' 13 rt. Red Clay
4.Date Well(s)Completed:3-28-2022 Well ID# 13 rr. 15 rt' Brown Sandcla
5a.Well Location: 15 ft. 365 ft. Granite
Kevin&Stacie Possinger ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
5117 Bigham Rd.Waxhaw 28173 f[. rt.
Physical Address,City,and Zip ft. ft. APR 2
7
Union 05-066-012B 31.REMARKS ,
County Parcel Identification No.(PIN)
£r l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Q`ESSII U;
(if well field,one lat/long is sufficient) 22.Certification:
34.53.289 N 80.42.784 W
4-7-2022
6.Is(are)the well(s)(OPermanent or OTemporary Sfgffrure of Certified We Contractor Date
By signing this form, I hereby certify that the ivell(s)was(were)const-ticted in accordance
7.Is this a repair to an existing well: rJYes or RNo 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 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 1 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: 365 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nniltiple wells list all depths if different(example-3@200'and 2@100� constmetion to the following:
10.Static water level below top of casing: 38 (ft.
Division of Water Resources,Information Processing Unit,
If ivater level is above casing,use"+" 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 Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary
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) 60 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: 220Z 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