GW1-2022-09572_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Us (Only:
1.Well Contractor information:
Frankie L.Oliver a >T.Ea z� f� ; :��� ,:, �;�;;r .�y.<5 b.„p
FROM I TO DESCRn'TION
Well Contractor Name 185 n 231
3002-A
rt. rt.
NC Well Contrauor Certification Number
J 5.t0U,7VV,0'A�S1N f6Fv`ti iill(tii'ii�'d�iG�ils i3)ti`3i1NFlRz21Ps'ii" Il tiiii
Carolina Well Drilling FROM I To DIAMETER TWCKNLSS MATFauAL
Company Name 0 ft. 35 n' 61/4' t"' SDR21 PVC
k 16i"ll+if IEk(vi1�4IN n r [76W(,� fltelt Yr tYJ Ii eR liiif "d ;"r r
2.Well Construction Permit#: 22-89 FROM TO I DiAMETER TtncX FSS MATERIAL.
List all applicable ivBll corm fiction permits(i.e.UIC,Cotaav,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. [t. in.
Water Supply Well: :17t$fR
FROM I TO I DIAMETER ! SLOT SIZE I TRICRNPSS MATF.RTAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. m
IndustriaVCormnercial Residential Water Supply 1 (shared) =•s
1iGR1). ;
Irrigation FROM I TO MATERUL EMI'LACEbIENT MKMOD&AMOUNT
Non-Water Supply Well: 0 ft' 20,+ ft. Bentonite Pour 13 501b Bags
Monitoring CIRecovery
injection Well: ft [t
Aquifer Recharge ®Groundwater Remediation
09 6ATfi)/GR`.._. . `A'Cs1f Ir �ti:iilile..
Aquifer Storage and Recovery [:)Salinity Barrier FROM I To MATERIAL BMPLACENEKT MM41D
Aquifer Test ®Stormwatet•Drainage n n•
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13 Tracer =2 i1tRII 1iIN Ga{rig"`dJa tlS ifishieislfiled
FROM
TO nFSCItMION color,hard sotUroek rain size eta
lGeothermal(Heating/CoolingReturn) Other(explain under 421 Remarks) 0 [t. 20 n' Red Clay
4.Date Well(s)Completed: 9-19-22 Well ID# 21 n' 2 0 ft' Granite
59.Well Location: rt. ' n.
ft. ft.
Teleo, LLC =
FacilitylOwner Name Facility IDii(if applicable)
6626 Old Settlers Rd.Waxhaw 28173 Settlers Creek Lot#6 ft. 1 ft. OCT 2
Physical Address,City,and Zip ft fl. Vim
Union 05-096-002F21a Im i �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/udnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification;
34.52.455 N 80.43.558 W
9-26-22
6.Is(are)the well(s)OPermanent or Temporary Stg�f CeroSed Well Contractor Date
Av signing this form.1 hereby cenify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Jallo with 15A NCAC OiC.0100 or 75A NCAC 02C.0200 Well Constntction Standards and that a
If this is a repair,fill mu burin well rnnstntclinn infiirmatinn aril explain the nature of the enpy of this record ham been provided to the well awner.
repair tinder#21 remarks section or on the back of this forni. 23.Site diagrar�l or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the buck of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction devils. You may also attach additional pages if necessary.
drilled: SUBMITTAL RUCTIONS
9.Total well depth below land surface: 250 (ft-) 24a. F r All Ils: Submit this form within 30 days of completion of well
For multiple wellc list all depths ifdifferent(example-3@200'and 2WO01 construction to'he following:
I
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1' 17 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Ir ec on Wells: In addition to sending the form to the address in 24a
Air Rotary above, also su init one copy of this form within 30 days of completion of well
12.Well construction method: construction to a following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of ater Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: J636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test- Air 24c.For Watr Strouly&InJection Wells: In addition to sending the form to
the addresses above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount• 150Z completion of well construction t the county health department of the county
where consttu ed.
C
From GW-I North Carolina Department of Environmental Quality-Divi.ion of Water Recounts Revised 2-22-2016
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