GW1-2022-09575_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.,NVATFR Z5RKS�
FROM TO DESCRHITION
Well Contractor Name
89 108
3002-A 119 165
NC Well Contractor Certification Number 1&,OUTER CASING(for multi-cased Wells)OR LINER(if ip HS2,111e)
Carolina Well Drilling FROM TO I DIAMETER THICKNESS MATERUL
Company Name 0 ft. 73 r" 6 1/4 In' SDR21 PVC
J6.-E1;NERC,&1;ING­0RT ING'fii6theetcLaidoscd-l000).�,I
18-353 FROM TO DIAMETER THICKNESS MAT
2.Well Construction Permit#: I
ERIAL
List all applicable well construction peinifts(i.e.UIC,County,State,Variance,etc.) ft rt in'
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO THAMFTRR SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) WRe.-idential Water Supply(single) -f t. ft. in.
Indusuial/Commercial [3Residential Water Supply(shared) 48;'GROIJT­,'�,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20+ Bentonire Pour(24)501b Bags
Monitoring ®Recovery ft. ft.
Injection Well: ft.
)Aquifer Recharge OGroundwater Remediation
�19:SANDIGRAVET,PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO NUTERIAL EMPLACEMENT METHOD
Aquifer Test [3 StormWater Drainage ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) ®'racer 20.DRILLING'LOG(attach addititifilal sheets Jif necessary)
Geothermal(Heating/Cooling Return) _ Other(explain under*21 FROM TO DFSCRTPTION(color,hardness,sefffrock tyiie,grain size etc)
0rf10 Red Clay
4.Date Well(s)Completed: 9-28-22 Well ID# 10 175 Granite
5a.Well Location: it. ft.
Myron&Rebecca Cox ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft. R E 11-1
6317 Big Horn Ln.Waxhaw 28173 Deer Track Estates Lot#3
Physical Address,City,and Zip ft. ft. OCT 2 1 2022
Union 05-101-049
County Parcel Identification No.(PIN) DWQIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
34.51.503 N 80.43.166 W 10-5-22
6.Islam)the well(s)OPernitattent or [)Temporary Signamre of Certified Well Contractor Date
By 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 RNo with 15ANCAC 02C.0100 or 15A 1VCAC 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 cnpy of this reenrd has been provided to the well owner.
repair tinder#21 remarks section or on the back of this farm. 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 pageAii provide additional well site details or well
construction,only I 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: 175 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a_)200'and 2@U00D construction to the following:
10.Static water level below top of casing: 19 10 Division of Water Resources,Information Processing Unit,
If water level is above casing,itse 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 2769 9-1 636
13a.Yield(gpm) 100 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: 12oz 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