GW1-2023-01791_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L. Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3002-A
119 r`• 139
—
222 r`' 288 r`' 323,350,432,472
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR i,11 (if a icable
Carolina Well Drilling FROM TO DIAMETER TITICKti[iti5 MATERLAL
Company Nam 0 ft. 105 r`' 1 61/4 1°' SDR21 PVC
21-77 ILL INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATFRt Ai.
Agricultural [3Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) 53Residential Water Supply(single) tt. tt in.
Indusmal/Cominercial 13ResidenEial Water Supply(shared) IS.GROUT
Ilrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 [c. 20+ n Bentonite Pour(29)501b Bags
Monitoring Recovery
injection Well:
ft. ft.
Aquifer Recharge E3 Groundwater Remediation 19.SAND/GRAVEL PACK(if applic ble)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHt iD
Aquifer Test ®Stormwater Drainage ft. ft.
Experimental Technology ❑Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness soll/rock t rain size etc.)
Geothermal(Heating/CoolingReturn) . Other(explain under#21 Remarks) —
0 f`. 39 ft, Red Clay
4.Date Well(s)Completed: 12-12-22 Well ID# 39 f`' 95 Brown Sandcla
5a.Well Location: 95 ft. 625 r`' Granite
Ross Allen ft. ft.
Facility/Owner Name Facility ID#(if applicable) Ct. ft. - t
3117 Waxhaw-Marvin Rd.Waxhaw 28173 Valhalla Farms#2 ft. n. J 2
Physical Address,City,anJ Zip
Ft. ft.
Union 06-189-072 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.58.502 N 80.47.107 W
1-9-23
6.Is(are)the well(s)OPernranent or QTemporar} Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)war(were)consirucled in accordance
7.Is this a repair to an existing well: []Yes or 5INo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill our known well conrtruction infrnmatitm and explain the nature of the copy a f thir record has been provided to the well owner.
repair under#21 remarks section or on the bact of this 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 well
construction,only I GW-i 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: 625 (i1) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivelis Iirt all depths if different(ex onple-3@R(10•and 2@100� construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If awter level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also subunit 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 27699.1636
13a.Yield(gpm) 9 Method of test: Air 24c.For Water Supply&Injection 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: 36oZ 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