GW1--04448_Well Construction - GW1_20230710

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WELL CONSTRUCTION RECORD (GW-1) ForInternal;Uce Only:
1.Well Contractor information:
Frankie L.Oliver 414 AWATER•.ZONES.. v ri,,. .
Well Contractor Name FROM TO! DES2Rn"fION '
3002-A 62 ft' , 376' ft' ' I
435 ft. 472 re. I
NC Well Contractor Certification Number ' "SA)LiTF.R'CASiNGYfoedruid4Saed iveil3)ON'IiINP.R.tlrip'licahlc)1.
Carolina Well Drilling FROM TO I 1 •DIAMETER THICKNESS MATERIAL
Company Name0 ft. 44 it: ;6I114 in' SCR21 PVC
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22-56 +`rlCINNER'CA.SING'OR TIEING:.(geothermal claseddooji)' lz .S
2.Well Construction Permit II: • FROM TO i•' DIAMETER THICKNESS MATERIAL
Listollapplicablewellconstructionpeianits(i.e.U1C,County,State,Variance,etc.) ft. i'• ft. In.
3.Well Use(check well use): :ft. ft. In.
Water Supply Well: >t7:SCREEN t ' i . ;, i ;:.;, .i
PP FROM TO 1 r. DIAM�'R SLOT SIZE I THICKNESS MATF.RIAI
0Agricultural II Municipal/Public ft. ' l`ift. `. I in.
li Geothermal(Heating/Cooling Supply) EaResidentiai Water Supply(single) j ' in"
DIndustrial/Comtnercial Residential Water Supply(shared) :„IR.:GROUT t _:` :` a,,i: ,. ;', l > .> '' .t w.,
',Irrigation FROM TO I `.MATERIAL EMI'LICEMENTMETHOD&AMOUNT.
Non-Water Supply Well: : 0 ft' :20+ ft' Behtonite Pour(15)501b Bags
°Monitoring 'Recovery it. ft.
Injection Well: ft, ft.
Aquifer Recharge �GroundwaterRemediation t9:'SAND/GRAVF.i�AACK(if a' liable) J'
Aquifer Storage and Recovery Salinity Banter FROM TO l'' MATERIAL EMPLACEMENT MThI11D/
Aquifer Test ®Stonntvatet Drainage It. t1.
DExperimental Technology DSubsidence Control ft. ft. ,
C Geothermal(Closed Loop) Tracer `,20.,DR1I:LING'LOG hittuci additional ilieets ifi eciisary)>, s+ ,s`, i• =s<
FROM TO'';; DFSCRiP.'PION(color,hardness satllrock type,grain alee,etch
c3Geothermal(Heating/Coding Return) 11 Other(explain under ft21 Remarks) ,
0 ft 15. ff Brwn Clay/Rock
4.Date Well(s)Completed: 4-18-23 Well ID#I 15 n' 500 ft' G.anite .
5a.Well Location: It. ft. r-- _ _
Jacob Chandler fI. 1 f~m:m,,,1dn 1,.::-.1,.::-.$ f h. " g? '
Facility/Owner Name Facility IDlt(if applicable) ft. It. I J l I 1 9 [�art n 23
3724 Waxhaw Marvin Rd.Waxhaw 28173 :ft. ft. 1
ft. ft. tn;vc-r:..: a='r.-.c .`:45r": Uri
Physical Address,City,and Zip n a..-•+.,;(-).r••
Union 06-192-005E 21eREM•iRicsuii1 .., E. 1r,.n* nub..Trs, a . ';= ,,,, a+iw.>;i ...
County Parcel Identification Nu.(PIN) i
5b.Latitude and longitude in degrees/lninutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22.Certification:
34.57.200 N 80.46.241 ��
1 5-16-23
0.Is(are)the well(s) Perihanerit or Temporary Signature of Certified Well Contract r Date
By signing this farm,I hereby certify that the wells)w(u•(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConstructIon Standards and that a
If this is a repair,fill out!mounted!consmwtirnt inft rmation and ezplaut the nature of the copy of this record has beenpmvidri to the well Honer.
repair under#21 remarks section or on the bark of this form. 23.Site diagram ar additional well details:
You may use the'hack of this age to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I OW-I is needed. Indicate TOTAL NUMBER of wells U
construction details. You may Aso attach additional pages if necessary.
drilled: SUBMITTAL INSTR CTIO4S
9.Total well depth below land surface: 500 (ft-) 24a. For All Wells: Submit(this form within 30 days of completion of well
For multiple wells list all depths ft-different(example-3200'(a� and 2(0100) construction td the following: ,
10_Static water level below top of casing: 42 (ft.) D1vislop,of Water R 'purees,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servi a Center,Raleigl t,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In :ddition to sending the form to the address in 24a
Air Rotary above, also submit one copy o this form within 30 days of completion of well
12.Well construction method: construction to thfollowing:
(i.e.auger,rotary,cable,direct push,etc.) , '
Division of Rater Resour - ,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servi e Center,Raleigt,NC 2769 9-1 63 6
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13a.Yield(gpnr) 14 Method of test: Air 24c.For Water Su..1. &In ection Wells: In addition to sending the form to
the address(es) dhve, also s bmit'one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 30oz completion of,weil constiucti to the county ealth department of the county
where constructed.
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Potm GW-I :North Carolina Department of Environmental Quality-Diviscion of Water Reso reel i Revised 2-22-2016