GW1--05817_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Ur.• d Only: • .
1.Well Contractor information: • I
I 1
Frankie L.Oliver '=.14hwaTER'.zoNEsF „ l -.,. ,. .. ;�, '' `
Well Cunnaetnr Name FROM TO'I 1 DESCRIPTION
70,80 ft. 106 i fit.
3002-A J168,179 •
NC Well ContractorCertification Number .:15;:ouTEtfCASIN6:(frik Whitt ed ellsOR_LINER(Kan-161610 P,:i
Carolina Well Drilling FROM ' TO .l i DIAMETER', THICKNESS ' MATERIAL
Company Name •
O ft. 57 tt' 61/4r i"' SDR21 PVC
!'i6-INNER CA`SINCG�OR TUBING;(geothertnal closed laop)` A', ;i
2.Well Construction Permit 4: FROM FROM • To 'II ' ' DIAMETER' THICKNESS ' • MATERIAL
List all applicable well construction pennils(i.e.UIC,County,State,Variance,etc.) ft. 1 ;, ft, I In,
3.Well Use(check well use): ft. ft. P in,
Water Supply Well: . . 117.SCREEN ` -1l? 'In..;,0, c '',r',. ,:`4 .k,:....,:
FROM TO J� DIAntFT R , SLOT SIZE THICKNESS MATERiAi
Agricultural l MunicipaUPublic rt, , ,II I in.
Geothermal(Heating/Cooling Supply) EaRecidential Water Supply(single) ft. :ft' tin
Industrial/Commercial DResidential Water Supply(shared) ' IR:`GROUT.. , :'?. o ;1 ' :i ?N „,s n>,
Irrigation FROM • TO I{ MATERIAL EMPLACEMENT METHOD&AMOUNT ,
Non-WaterSupply Well: 0 ft' 57I ft' Bertonite Pump(9)501b Bags
Monitoring . :aRecovery ft. ft. I'
injection Well: ft. ft.
Aquifer Recharge ®Groundwater Rernediation
19 StiND/GRA :Et PACK'(II applicable)AI a ,i. %.6;;:.W; ,.,.., •?5 g'-'NC
Aquifer Storage and Recovery Ea Salinity Barrier FROM TO''I 11 VITT iAL ' . EMPLACEMENT METHOD
Aquifer Test 'OStormwater Drainage
fit. ( ft.
Experimental Technology ®Subsidence Control ft. i tt.
Geothermal,(ClosedLoop) OTracer • 20'.DRILLING'>It)Glottaeli.itdditientil'siieefs'ifnecessary)?_ f :. zs esg i$
FROM TO {I, DESCRiPTiON(color,hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under 421 Remaiks)
0 et. 10.1 it. Reel Clay •
' n. i
4.Date Well(S)Completed: 6-28-23 Well ft.ID# 10 17.I Brown'day
Sa.Well Location: 17 ft' 200 tt' Granite r°' r)
Waxhaw Bible Church fit, {I tt, 'a�""�.+'
Facility/Owner Name .Facility IDS(if applicable) ft. I tt' S E p: 0 1 2023
6810 Pleasant Grove Rd.Waxhaw 28173 fit ` ft. i e, U,�$
1 tnfatr,'-r n,
Physical Address,City,and Zip rt. ft. Cep(1"? W
Union 06-084-001 H60 ,z 'REMARICSY:s-;1 ;a;;„µ4,..,. . r: ;K ;1, .• .t.. . n'1-.}:=>
County Parcel Identification No.(PIN) J .
*Full length casing grout Os required*
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one ladlong is sufficient)
22.'Certification: ;
�
34.56.355 N .80.43.154 W
c--,( _ /owl 7-12-23
F.Is(are)the well(s)MPermanent or Temporary Signature of Certified:Well Contractor , Date
By signing this farm.' hereby cent j'that the well(s)*as(were)eon(trucled in accordance
7.Is this a repair to an existing well: DYes or IONo with 1SA NCAC 02C t 100 or!SA 1 CAC 02C.0200 Well Constnictlou Standards and that a
If this is a repair,fill out laonrm well cogstntctimu information awl eaplahl the nature of the copy of this record ha�been provide to the well owner.
repair under 1121 remarks section or on the back of this form. 23.Site diagram o}}'additional ell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the b sck 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`lt You may also attach additional pages if necessary.
drilled: .SUBMITTALINISTRUCTIONS '
9.Total well depth below land surface: 200 tit.) I i
ep 24a. For All Wells: Submit' is form within 30 days of completion of well
For ntuhiple wells list ail depths((different(exaimple.3L200'and 2@Ioo') consttttction to'the}'ollowing:
•t0.Static water level below top of casing: 32 (ft.) Division f Water R{ onrces,Information Processing Unit,
If wafer level is above casing.use"+" '1611 Mail Servi Center,Raleigh,NC 27699-i617
11.Borehole diameter: 6 •(in.) 24b.For In et tlon Wells: In ditioti to sending the form to the address in 24a
Air Rotary above,also subini one copy'o this;form within 30 days of completion of well
12.Well construction method: construction to;the ofowing:
(i.e.auger,rotary,cable,direct push,etc.) . 'I
•Division of'Wa er Resourc ,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163 Mall Seryite Center,Raleigh,NC 27699-1636
13a.Yield(gpm) '40 Method of test: Air 24c.For Water 1 &In ectlon Wells: In addition to sending the form to
the address(es) a ve, also's bind;one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oz completion of wi, construed to the county health department of the county
where constructed.i
Form OW-I - North Carolina Department of Environmental Quality-Division 1
Water Resources Revised 2-22-2016