GW1-2022-10582_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW-1) For Internal Us;d Only:
1.Well Contractor information:
Frankie L.Oliver
FROM I TO i DESCIM'TION
Well Contractor Native
3002-A 145 n 156
165 ft' 215' n'
NC Well Contractor Certification Number a/($ UT Al
.`
(s i iluttl car r ell§fOR;Ts1iYf Rtt ifxg `II}abli
Carolina Well Drilling FROM I To ' i DIAMETFdt THICKNESS Meru 41.
Company Nature 0 ft. 133. n' 61/4 In' SDR21 PVC
65xIP1KR ilS1CN, t1131N. a 'et1n;;lItfiedtoo � :,« _. .
2.Well Construction Permit#: 22-165 FROM To E DIAMETER 7MCi NESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) n. ft.
3.Well Use(check well use):
Water Supply Well: FROM TO n1AMrTF.R StOTSIM I•TMCKNPSS MATERIAL
Agricultural 13MttnicipaYNblic ft. ;ft. in.
Geothermal(Heating/Cooling Supply) 511tesidential Water Supply(single) ry n- In.
Industrial/Cormnercial ®R.esidendal Water Supply(shared)
Irrigation FROM TO tO MATEAL EMPLAC1:114SPtTMETROD&AMOUNT
Nan-Water Supply well: 0 rt. 20+ n Bentonite Pour(94)501b Bags
Monitoring Recovery ft. ft.
injection Well: ft tt.
Aquifer Recharge ®Groundwater Remediation t 1ti fS7►NOJGR' ', i1j51ff 1tiblh r'-" "'"` soli
Aquifer Storage and Recovery aSalinity Barrier FROM TO I I MATERIAL EMPL#.L7 MFdv'rME1TltrD
Aquifer Test E3Stormwates'Drainage
ft. ft.
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) ®Tracer RI1s1�1NG 1 'G ftaji:tiit8ltliilial`3teelaessg t aEiz ry_ '. i:fh
Geothermal eatirt /C oling Return) Other(explain under 421 Remarics FROM I To i nFSCRTPTTON ferilar,hardness to111mck lYm grain We etc
0 f`' 6 n' Brown Dirt
4.Date Wells)Completed: 10-4-22 Well ID# 6 tl' 50 n' Red/Brown Clay
sa.Well Location: 50 n' 120 I1' Brown Roc a -i -
James Gray
..
120 rt• 2�0 It• Granite Facility/(Tuner Name Facility IDN(if applicable) tt. fl. N O V 2 2 202
Harrington Hall Lot#3 Waxhaw 28173 ft. n.
'Physical Address,City,and Zip
Union 06-060-043 21 OR►1 4 ^w
County Patul Identification No.(PIN)
5b.Latitude and longitude In degrees/minutesfseconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification:
34.56.392 N 80.42.180 W
11-1-22
6.Islam)the well(S)OPermanent or Temporary Signature of Certified VVell,Contractor Date
Ay signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: ®Yes or SINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this it a repair,fill our btrnr n well constnction information and explain the stature of the copy of this record has been provided to the wen nwner.
repair under#21 remarks section or on the back of dais 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 wel I
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
I
9.Total well depth below land surface: 250 (ft-) 24a. For All Welts: Submit this form within 30 days of completion of well
For mtdnple wells list all depths if different(example-3@4200'and 2@100) constriction to the following:
10.Static water level below top of casing: 34 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 2769 9-1 6 1 7
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also subihit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cubic,direct push,etc.) i
Division ofWater Resources;Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centex,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: Air 24c.For Water Supply&Injection Wells: in addition to sending the form to
the address(es)i above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amotmt 16oz completion of well construction to the county health department of the county
where constructed.
i
From GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016