GW1--04455_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES'.
FROM TO DESCRIPTION
Well Contractor Name
84 ft. 90 ft.
3002-A
146 ft' 165 ft' 179,183,294
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased`wells)OR LINER(if ap licable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 43 ft' 61/4 in' SDR21 PVC
23-82 16.INNER.CASING OR TUBING(geothermal closed-loop) .• ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17..SCREEN
pp y FROM TO DIAMETER SLOT SI7,F, THICKNESS MATERIAL.
Agricultural DMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) Dj Residential Water Supply(single) ft. ft. in.
Industrial/Cor unercial OResidential Water Supply(shared) 1R.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(16)501b Bags
Monitoring ORecovery ft. tt.
Injection Well:
ft. ft.
Aquifer Recharge El Groundwater Remediation
.19.SAND/GRAVEL.PACK(if applicable)Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater•Drainage
ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DT7acer 20.DRILLING LOG,(attach additional sheets if necessary)t
FROM _ TO DESCRIPTION(calor,hardness,sell/rock type.,grail size,etc.)
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks)
0 ft. 3 ft' Red Clay
4.Date Well(s)Completed: 4-11-23 Well ID# 3 ft. 18 ft' Brown Rock
5a.Well Location: 18 it 300 rut' Granite :-7::a " `s ,",=.Pn,
ft. ft. s s,- t;.,.s'R-..t `Vi m-,f ir
Waxhaw Marvin Swim and FL id1fl%nerName Facility ID#(if applicable) ft. ft. JUL 1 /�t1 2023
8302 Viking Dr.Waxhaw 28173 ft. ft.
li Physical Address,City,and Zip ft. ft. 4,0,y.V..,
Union 06-189-005B 21.REnIARxs .
County Parcel Identification No.(PIN)
*Well permitted as Transient Non-Community
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:
34.57.533 N 80.46.385 W
4,A . 5-1-23
6.Is(are)the well(s)5aPernmanent or [Temporary Signature of Ceitifie Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: II Yes or Eallo with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Consttauiian Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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: 300 (it) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a)200'and 2@,100') construction to the following:
10.Static water level below top of casing: 23 (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 Injection 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 13 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: 18oz 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