GW1-2022-09573_Well Construction - GW1_20221021

I
WELL CONSTRUCTION RECORD (GW-1) For Intanal Us I Only:
1.Well Contractor information:
Frankle L.Oliver
Well Cuntractur Name FROM TO UESCItn'TION
3002-A 113 et' 133 ft.
146 et' 1591 tt'
NC Well Contractor Certification Number t3 ()ti7lFtt'VAS 'I&iili'018F&95 4"`,'Wells 01211flIVKTf e�IJ
Carolina Well Drilling FROM Ttl DiAMETFdt ' TfclaSILSS MATERIAL,
Curnpany Name 0 ft 46 ft. 6114 In. SDR21 PVC
.1&: <CiA,CI. .£Alt" f11 t. fibi' tiG4lasB'd-Iris 17a7� r %
2.Well Construction Permit Il: 22-88 FROM TO DIAMETER T11110KNEss I MATERIAL
List all applicable well consnucdon prrmrits(i.e.U1C,County,State,Vailance,etc.) ft. ft. In,
3.Well Use(check well use): fL ft. in.
.
Water Supply Well: FROM I TO I IHAMFTFR , SLOT SI7.F. TAiCKNFM MATRRiAL
Agricultural ®MunicipaVPublic ft. fL in.
Geothermal(Heating/Cooling Supply) UPesidential Water Supply(single) fL ft. in.
IndustriallCommercial ®Residential Water Supply(shared)
Ini ation FROM TO I MATEMAL EMPLACEMENT METHOD h AMOUNT
Non-Water Supply Well: 0 ft. 2 + tt Bentonite Pour 23 501b Bags
Monitoring Recovery ft. tt.
injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation Fa tWAGKt(Itb• lI&6w N
Aquifer Storage and Recovery ®Salinity Barrier FROMTO MATERIAL EMPLACEMENT MET1141D
Aquifer Teat Stormwater Drainage
ft.
Experimental Technology Subsidence Control ft.
Geothermal(Closed Loop) ®Tracer NG Geothermal eatin /Coolie Return Other ex lain under#21 Remarks TO nFSCTVlMON(color bardnea sotUrock roln sBe etc)
1,2 Brown Cla4.Date Well(s)Completed: 9-22-22 Well IDk 21Br wn Rock
5a.Wen]Locatlon: 200 n.
Granite
Teleo,LLC
ft. a. F.. ..t 1
Facility/Owner Name Facility ID#(it applicable)
6623 Old Settlers Rd.Waxhaw 28173 Settlers Creek Lot#5 ff. tt' OCT 2 1 20ZZ
Physical Address,City,and Zip ft. i 1 rt.
Union 05-096-002E21t1tEtVlt�RtivC,;'; kl r. x `F ,.
County Pairel idea ificittiun No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.52.359 N 80.43.479 W
9-26-22
'lam
6.Is(are)the well(s) Pertuanent or Temporary a of C fed Well Contractor Date
By signing this Join 1 hereby cenV),char the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or UNo wish 15A NCAC 01 .0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill aut knentm well consruction informatinn and raplair the nature of the copy of!iris reenr hat been provided to the well anmer.
repair under#21 remarks section or on the back of this fann.
23.Site diagratit or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use tit 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 detiiiis. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth be i
low land surface: 200 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple ivelta list all depths ifdifJrrent(example-3(a3 00'and 2@100) construction to the following:
10.Static water level below top of casing: 29 (ft.) Division of Water Resources,Informadon Processing Unit,
If water level is above casing,use"+" 1 17 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (1n.) 24b.For in a on Wells: In addition to sending the form to the address in 24a
Air Rotary above, also so unit one copy of this form within 30 days of completion of well
12.Well construction method: construction to he following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of l ater Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1,636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 Method of test: Air 24c.For Wa r SuDDIv&I 'eecton Wells: In addition to sending the form to
the addrcss(csi above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oZ completion of well construction to the county health department of the county
where constructed.
i
Form OW-I North Carolina Department of Environmental Quality-Divjon of Water Resources Revised 2.22-2016
i
i