GW1-2022-09203_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver 14:WATER ZONES
FROM TO DESCRD-TION
Well Contractor Nazne
65 1" n.
3002-A ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING(for tnuiN-casedwelIs) a Ileable)'
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 24 fl' 61/4 i"' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop),
2.Well Construction Permit#• 22-274 FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well cunstruction permits(i.e.UIC,Cutmrv,State,Variance,etc.) ft. fl. in.
3.Well Use(check well use): et. ft. in.
Water Supply Well: 17.SCREEN_FROM
FROM TO DIAMETER SLOT SIZE. THTCKNFSS MAT IFRTAL
Agricultural 3Municipal/Public ft. (L in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it is J
:)Industrial/Commercial Residential Water Supply(shared) W GROUT,
_ Im ation FROM TO MATERIAL EMI-LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ fl. Bentoriite Pour(12)501b Bags
Monitoring Recovery ft. n.
injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAW..T,PACK(if a `licable)
"Aquifer Storage and Recovery EISAinity Barrier FROM I TO MATERIAL 7 EMPLACEMENT METHOD
_ Aquifer Test 13Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. I ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG(attach additional sheets if necessity)
FROM TO DFSCRTPTTON(color,hardness soil/rock rain slye etc)
Geothermal(Hearin /Conlin Return) Other(explain under#21 Remarks)
0 rc' 11 ft, grown Sandclay
4.Date Well(s)Completed: 8-18-22 Well ID# 11 rt' 600 «. Granite
Sa.Well Location: ft. ft.
Robert McGirt
N�--
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5002 Ander Vincent Rd.Waxhaw 28173 ft. ft. SEP t.
Physical Address,City,and Zip ft. ft. +.P-r. ,_ 'ns Mitt
Union 05-171-008 21.REMARKS DIN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.54.161 N 80.47.174 `Ir ��y
(fL�/ 8-19-22
6.Is(are)the well(s)Wermanent or Temporary Signature of Certified Well Contractor Date
Br signing this form.I hereby certify ihai the well(s)was(were)constructed in accordance
7.Is this a repair to an eldstiug well: Dyes or oNo with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
if this&a repair,fill out krvmw 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.
dtilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 600 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(ex-anple-3@201)-and 2(a31001 construction to the following:
10.Static water level below top of casing: 425 (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 Injection 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 2 769 9-1 636
13a.Yield(gpm) •10 Method of test: Air 24c.For Water Supply&Iniect ion 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- 36oZ completion of well construction to the county health department of the county
where constructed. I
Fmm GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016