GW1-2023-02843_Well Construction - GW1_20230420

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver ,44.WATER ZONES-'-"
Well Contractor Name FROM TO DESCRIPTION
3002-A 112 rc• 189 ft.
358 rt' 422 rc' 437
NC Well Contractor Certification Number 15.:OUTFR CASING'(for:multi:cased Hells)OR LINER(if a t(cable) .
Carolina Well Drilling FROM To DMETER THICKNESS MATERLU.
IA
Company Name 0 Ft. 109 rt' 6114 jm' SDR21 PVC
22-408 16.1NNER CASING OR TUBING( eot&erinal closed,lou )
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consmiction pennits(i.e.111C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. !t. in.
Water Supply Well: 47-SCREEN .,.• - =�s °:
FROM TO DIAMETER SLOTSTU. THTCKNF.SS' MATERTAT
Agricultural [3Municipal/Public ft. fL in.-
Geothermal(Heating/Cooling Supply) MResidentiaI Water Supply(single) R, fL in.
hidustrial/Cominercial OReeidential Water Supply(shared) 8 GROUT
IITi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. . Bentonite Pour(36)501b Bags
Monitoring Recovery ft. ft.
Injection Well:
_Aquifer Recharge Groundwater Remediation 19.SAND/GRAVFi,PACK Of applicable),
Aquifer Storage and Recovery Salinity Barrier FROM TO 11L4TERTAL FAI CEMENT METHOD
Aquifer Test EJStonnwater Drainage
Ft. Ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:•DRILLING LOG lattach additional sheets if necessary) -'_;
FROM TO DFSCRTPTTON(color,hardness solvrock raln size etc.)
Geothermal(Hea[in Coolie Return) i Other(explain under#21 Remarks)
0 rc• 15 !t. Red Clay
4.Date Well(s)Completed: 2-17-23 Well ID# 15 et. 93 ft.
Brown/Gray Sand/Gravel
Sa.Well Location: 93
Ft. 450 "' Granite r - -
ft. ft.
Angela Lawrence -
FacilirylOwner Name Facility ID#(if applicable) ft. fl.
7
Waxhaw Creek Rd.Waxhaw 28173 Triple C Mini Ranches#90 ft. ft.
Physical Address,City,and Zip
Union 05-159-001
REMARKS ,::_-.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
34.50.141 N 80.46.209 W
2-29-23
6.Is(are)the well(sQPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify Thai the well(s)was(were)canstrucled in accordance
7.Is this a repair to an existing well: [3Yes or JoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constritclion Standards and that a
If this&a repair,fill out him m well commictian information and explain the nature of the copy of this record has been provided to the well owner.
repair ender#i21 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 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: 450 Ut.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welis list all depths if&fferent(e vinple-3(a3200'and 2@100� construction to the following:
10.Static water level below top of casing: 55 (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
Air Rotary above, also submit one copy of this fonn 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) 20 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 font[ within 30 days of
13b.Disinfection type: 70% HTH Amount: 300Z completion of well construction t i e 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