GW1--04460_Well Construction - GW1_20230710

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WELL CONSTRUCTION RECORD (GW-1) ForInternaljUe Only:
1.Well Contractor information:
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Frankie L.Oliver ;,14.WATER ZONES i ',,::, 1 ;',1',', .
FROM TO 1 I DESCRIPTION
Well Contractor Name
3002-A 48 ft* 1,03 ft' 1
108 it' 1.12. ft' 115,1881
NC Well Contractor Certification Number 15r.011TFR CASING`(for.multi•ttried'wells)OR:'13NFW(If'ap ticable)"x - .
Carolina Well Drilling FROM TO 1" DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 43': ft' 611/4 in' SDR21 PVC
21-375 .:16:1NNER CASINC,"OR TUBING:(geothertnal;dosed loop) ., ,.
2.Well Construction Permit it: FROM TO I P DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) ft. ft. in. I
3.Well Use(check well use): ft. i. ft. in.
Water Supply Well:
FROM TO 1 DIAMETER SLOT SIZE 1 THICKNESS MATF.RiAI,
Agricultural •Municipal/Public fL rill.iL In.
Geothermal(Heating/Cooling Supply) Ea Residential Water Supply(single) ft. I,.it. In.
Industrial/Commercial ®Residential Water Supply(shared)
Irrigation FROM TO I, MATERIAL Et1II LACEMF.Nf METHOD&AMOUNT
Non-Water Supply Well: 0 it• '2U+ R' Bentonite Po�lr(18)50lb Bags
Monitoring �Recovcry tt. ft. I
injection Well:
ft ft.
0Aquifer Recharge 0 Groundwater Rernediation
19::SAND/GRAVFT:PACK(lf_ap'pllcable) f , :'' :r C-rY:
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO i" MATERIAL EMPLACEMENT METHOD
J Aquifer Test 0Stormwatet Drainage
ft. ft.
DExperimental Technology DSubsidenceControl ft. ft. ,
DGeothermal(Closed Loop) EjTracer 20.:DRILLING'I,OG iattash riddhional'sheets if neces:cun.) ,` i`''
"'Geothermal(Heating/Cooling Return) L 't Other(explain under 421 Remarks) PROM TO;? DESCRIPTiON(color,hardness soil/reek type,stain size et�l
0 it' 19 ft• Brpwn Clay/Rocl�
4.Date Well(s)Completed: 6-6-23 Well ID# 19 rt. 30 11. Gray Clay !!
5a.Well Location: 30 ft' 200 ft' Granite
Serghei Meradji ft' R.
Facility/Owner Name Facility IDtt(if applicable) ft. ft. f
2705 Harrington Place Waxhaw 28173 Harrington Hall#13 rt. ft. . I �y'j
Physical Address,City,and Zip ft. ft. J iJ L u 3
Union .06-060-053 .21:.'REM4RKS'itools . _ i•.a.ff,;, ( �, ;Yl,.t:
County Parcel Identification No.(PIN) I I r_..
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.30.485 N 80.34.222 'V
��s{ , ��r' 6-16-23
6.Is(are)the well(s)RIPermanent or DTemporary Signature of Cerii i d Well Conuaclor Date
By signing this form,1 hereby evil fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or EijNo with ISA NCAC 02C.iiioo or ISA KCAL 02C.0200 Will Construction Standards and that a
if this is a repair,fill out/amen 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 arditiunal 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 JNSTIRUCTIOI IS
9.Total well depth below land surface: 200 (T1.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(ai200'and 2(t!00) construction to the following:
.to.Static water level below top of casing: 37 (ft.) Division of Water Iesources,Information Processing Unit,
if water level is above casing,use"+" 1611 Mail Servi Center,Raleig t,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to seudi,g the form to the address in 24a
Air Rotary above, also si}brpit one copy f this form withi 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 Resour5es,,Underground injection Control Program,
FOR.WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleig r,NC 27699-1636
13a.Yield(gpm) 18 Method of test: Air 24c.For Water'Supply &Injection Wells: addition to sending the form to
the address(e) above, also submit one copy .f this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oz completion of well constructi to'the county ,ealth department of the county
where constructed, 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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