GW1-2023-02840_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver ° 14:wATER ZONES. -
Well Cuntractor Name FROM TO DESCRH'TION
3002-A 75,81 ft' 87,95 ft.
103 ft, 114 ft, 118,134,146
NC Well Contractor Certification Number 15,OUTRR CASING(far.multi-cased wells)OR LINER(if a ticable)'
Carolina Well Drilling FROM TO DIAMETER 7111 V111i 11tATERLAL
Company Name
0 ff 68 ff 61/4' in' I SDR21 PVC
16..INNER CASING:OR TUBING,(geothermal closed-lob
2.Well Construction Pennit#: 22-268 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. Cl. in.
3.Well Use(check well use): [t. tt. in.
Water Supply Well: 17.SCREEN`,
FROM TO DIAMETER SLOT SI7.F. THICKNESS MATERIAL
:]Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) laResidential Water Supply(single) fL ft.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
h7i ation FROM TO MATERIAL Ebn'LACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20+ n. Bentonite Pour(24)501b Bags
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation 19 SAND/GRAVFT PACK(if applicable)
Aquifer Storage and Recovery C]Saliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stonruwatet-Drainage ft. Ft.
Experimental Technology 13subsidence Control ft. ft.
Geothermal(Closed Loop) 1I Tracer `20.DRILLING LOG{attach additional sheets if necessa )
FROM TO DFSCRTPTTON(color,hardness soiltrock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 9 ft, Red Clay
4.Date Well(s)Completed: 1-16-23 Well IDY 9 ft. 31 ft- Brown Sand
5a.Well Location: 31 ft. 47 It. Brown Sand/Gravel
Scott Welles 47 ft• 150 f' Granite
t.
Facility/Owner Name Facility ID#(if applicable) f � -- -
2,
6324 Providence Rd.S.Waxhaw 28173 Easton on Providence#4 rt. ft.
Physical Address,City,and Zip
Ft. ft.
AFR
Union 05-063-007C 21.REMARKS-'
County Po ruel Identification No.(PIN) r,t h^J=sl?i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lac/long is sufficient) 22.Certification:
34.89.539 N 80.72.138 -� 2-14-23
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor, Date
By signing this form,7 hereby certify that the well(s)ivas(were)consirucled in accordance
7•Is this a repair to an existing well: [3Yes or E?No iviih 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill out knoitn hell construction information aim]explain the nature of the copy of this record has been provided to the well owner.
repair tinder 1121 remarks section or on the back 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-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: 150 (ft-)
24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells lictall depths ifdifjerent(eximple-3@200'and 2(a3100D construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 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
12.Well construction method:
Air Rotary above, also submit one copy of this form within 30 days of completion of well
i.e.auger,ro• construction to the following:
(' g toy,cable,direccpush,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) 100 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subunit 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i