GW1--04458_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor information:
Frankie L.Oliver ^'14.WATER ZONES '' "-
FROM .TO DESCRIPTION
Well Contractor Name
98 ft' 105 ft.
3002-A
119 ft' 162 ft-
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
0 ft' 89 ft' 61/4 in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING"(geothermal closed-loop): ..
2.Well Construction Permit# 23-43 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.
17.SCREEN.' i.. '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural ['Municipal/Public ft. ft. in.
1111 Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) it. ft in,
Industrial/Comrnercial Residential Water Supply(shared)
s
Fah-ligation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft. Bentonite Pour(32)501b Bags
E3Monitoring ['Recovery ft. ft.
injection Well:
ft. ft.
['Aquifer Recharge ['Groundwater Remediation
19.SAND/GRAVEL.PACK(if applicable)
['Aquifer Storage and Recovery ['Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
❑IAquifer Test ['Stormwater Drainage
ft. ft.
['Experimentai Technology ['Subsidence Control ft. ft.
3Geothermal(Closed Loop) ['Tracer '20..DRILLING LOG(attach additional sheets ifnecessary)„,"..
Geothermal(Heating/Cooling Return) r,)Other(explain under 421 Remarks) FROM TO nFSCRIPTION(color,hardness,soil/rock type,grain sloe,etc-)
0 ft' 11 ft. Red Clay
4.Date Well(s)Completed: 4-25-23 WellID/ 11 ft. 81 ft' Brown Sandclay
5a.Well Location: 91 ft' 200 ft' Granite
Thomas Viscount ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ^-" ^,g_Y r-i, f 5-.-r F
3320 Sandalwood Dr.Waxhaw 28173 ? .ov. Rd. Esr ns iF4g ft. ft. ~: 't.;.....A„'s...t IT 4_—'.
Physical Address,City,and Zip.
ft. ft. JIJL 1 0 2023
Union 06-213-057 21.REMARKS
Inf—.,;r 5icfn Pr'';' ' Una
County Parcel Identification No.(PIN) i air,:--,-,v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.95.326 N 80.79.224 W ___C--- ,•W-o2 5-16-23
6.Is(are)the well(s) Pernranent or ['1 Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: INI Yes or [2:1No with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction 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 Ill]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-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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-40(J0'and 2(J100') construction to the following:
10.Static water level below top of casing: 45 (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 Rotaryform above, also submit one copy of this 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 2769 9-1 63 6
13a.Yield(gpm) 23 • 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: 12oz completion of well construction to the county health department of the county
where constructed. 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016