GW1-2022-10587_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver 14.WATER ZONES
FROM TO DESCRD'TION
Well Cuntractur Name
97 "• 139
3002-A 145 f`' 186 f`' 217 255
NC Well Contractor Certification Number 15.OUTFR:CASING(for multi-cased bells)OR LINER(iF a livable)
Carolina Well Drilling FROM To DIAMETER THICKNESS MATERIAL
0 f`. 83 f`' 6 1/4' ' SDR21 PVC
Company Name
22-243 16.INNER CASING OR TUBING( mthermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TM MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
ft. fL
3.Well Use(check well use): in.
.17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TTTTCKNFSS MATF.RTA1,
Agricultural ElMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
:]Industrial./Commercial E311esidential Water Supply(shared) 1$.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 20+ f` Bentonire Pour(19)501b Bags
Monitoring ORecovery
injection Well:
ft. Ct.
.)Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if a livable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METH(ID
Aquifer Tee[ E)Stnnnwater Drainage
ft. ft.
Experimental Technology OSubsidenec-Control it. it.
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG(attach additional sheets ifnecema );
_ Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DFSCRTPTION(color,hardness soil/rock tyM grain she etc)
0 f`' 74 f`' Red Clay
4.Date Well(s)Completed: 10-7-22 Well ID# 74 f`' 300 f`' Granite
5a.Well Location: ft. ft.
Mark Bivens ft. ft' ;e w�. a. �Fy 14 s
Facility/Owner Name Facility IDN(if applicable) ft. ft.
1000 Baron Rd.Waxhaw 28173 Aero Plantation Lot#84 ft. ft. NOV 2 .9 LULL
Physical Address,City,and Zip
Union 06-129-086 2'1,REMARKS O!•;� '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lac/long is sufficient) 22.Certification:
34,59.485 N 80.45.504 `I,
10-19-22
6.Islam)the well(s)mPertnanent or MTemporary Signature of Certified We ontractor 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 JoNo with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out boon well camtnu lion information and explain the nature of the copy of this record has been provided to the well owner.
repair under#121 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 page to provide additional well site details or wel I
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.Totalwell depth below land-surfacc- 300 ML) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wel&list all depths tfdii ferent(example-3@a 200'and 2g100') construction to the following:
10.Static water level below top of casing: 54 (ft.) 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 Infection 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: 163.6Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 17 Method of test: Air 24c.For Water Supply&IDiection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this for within 30 days of
13b.Disinfection type: 70%HTH Amount: 18oZ completion of well construction to form within
the county health department of the county
where constructed.
Fmsn GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I