GW1--05814_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor information: -
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Frankie L.Oliver ,'.14'.WATER-ZONES,. `< .,, .(' .r
Well Contractor NameFROM TO DESCRIPTION
78 ft. 90 ft. 1 I
3002-A
106 ft' 112 ft' 125,130,1139,156,162
NC Well Contractor Certification Number 15.iOL1TER'CASING(for multi-cased wells);OR LINER(if ap limbic) ' '
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
0 ft. 76 ft' 61/41 IP' SDR21 PVC
Company Name
.i6.=INNER CASING OR TUBING(gedtherinal closed-loop) '.
2.Well Construction Permit#: 22-433 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. I, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN j ; V FROM TO DIAMETER I��SLOTSIZE THICKNESS MATERIAL
MI Agricultural DMunicipal/Public ft. ft. in. , '
Ng Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it. B- in.
DIndustriallCotmnercial ORe.sidential Water Supply(shared)
OIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(32)50Ib Bags
°Monitoring EIRecovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation S
19:.SAND/GRAVEL;PACK(if applicable) ' `
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL - EMPLACEMENT METHOD
0 Aquifer Test •'StormwaterDrainage ft, ft.
JExperimental Technology 0Subsidence Control ft. ft. I
P
RGeothermal(Closed Loop) Ng Tracer '20:'DRILLING LOG{attach additianal,sheets if necessary),' .3'•
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,etc-)
0 ft' 6 ft' Red Clay
4.Date Well(s)Completed: 6-16-23 Well ID#1 6 ft' 18 ft' Brown'Dirt
5a.Well Location: 18 ft' 70 f' BrownlRock
Allison's Custom Construction 70 ft' 175 ft' Granite E, E ,.)
Facility/Owner Name Facility IN((if applicable) ft. ft.
Couick Rd.Waxhaw 28173 ft. ft. SEP 12CI.J
Physical Address,City,and Zip ft. ft. it In(ICr4Niit1CTl PrC-C e UrA
Union 05-039-007 �;2.1.REMARKS Cr'' :4:10 C1P2/4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lac/long is sufficient) 22.Certification:
34.53.244 N 80.41.146 W
{ 7-10-23
6.Is(are)the well(s)MPermanent or Temporary Signature of Certified Well Canhactor I 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: ii Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 102C.0200 Well Construction Standards and that a
If this is a repair,fill our 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. I
23.Site diagram or additional well details:
S.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
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9.Total well depth below land surface: 175 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@201)'and 2(a)I00') construction to the following: i
10.Static water level below top of casing: 22 (ft.) Division of Water Resources;Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cenfter,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.) . f
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 45 Method of test: Air 24c.For Water Supply&Infection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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