GW1--05820_Well Construction - GW1_20230901

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information: i'
Frankie L.Oliver 14.WATER ZONES - ''i.11 ' ,
WellCuntruwrNune FROM TO DESCRIPTION
3002-A 88 of 103 ft. '
114 ft' ft. I
NC Well Contractor Certification Number 15.OUTER CASING:'(for,multi-cased'wells)OR CiNER(if:ap licable)
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft. 82 ft' 6 1/4 1 i"' SDR21 PVC
23-187 16.INNER,CASING OR TUBING(gedthertnahclosed-loop)'. " •.
2.Well Construction Permit# FROM TO DIAMETER ' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UJC,County,State,Variance,etc.) ft. ft. , in.
3.Well Use(check well use): ft. It. In.
17.SCREEN
Water Supply Well: FROM TO ' DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.,
NI Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in. "
DIndustrial/Comrnercial E3Residential Water Supply(shared) ' -
.1R..GROUT �• ...
ahlrgation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20+ R• Bentonite Pour r(24)50Ib Bags
s
12Monitoring QRecovery ft. ft.
injection Well: IL It.
Aquifer Recharge 0 Groundwater Remediation
•19.SAND/GRAVEL,PACK(if applicable) " . If'-'' i. - •.
II
Et Aquifer Storage and Recovery OSallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test 0Stonnwater Drainage ft. ft.
OExperimental Technology Subsidence Control ft. ft. '
1
DGeothermal(Closed Loop) lI Tracer 20 DRILLING LOG.(attach additioital'sheets if nec"essary)e,, :' , *r,
/Conlin Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,Ole.)
Geothermal(Hearin g g Other(explain under#21 Remarks)
0 ft' 5 ft' Red Clay
4.Date Well(s)Completed: 8-4-23Well ID# 5 ft. 68 ft' Brown Clay
5a.Well Location: 68 et' 200 rt• Granite
Patricia Smith ft. n. l %�. ;
•
Facility/Owner Name Facility 1D#(if applicable) ft. ft. 1 t''1,,L-,.�,.,d III i V 1.....
5307 Waxhaw-Marvin Rd.Waxhaw 28173 ft. ft. '` SEP J 1 2023
ft. ft. •
Physical Address,City,and Zip 1
Union 05-138-031 ,21.`REM4RKS.a ;--- . ' �',• in,Uriv�.t ar?, 1.r1
DViCti.50ttr
County Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification:
34.92.709 N 80.75.667 w
c___ ;;A(2� +, 8-21-23
6.Is(are)the well(s)MPermanent or 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: a Yes or ONo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an]eaplain the nature of the copy of this record has been provided tothe 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 INSTRUCTION S
depth below land surface: 200
9.Total well (ft)
24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-9@200•an12(a)T 00') construction to the following:
10.Static water level below top of casing: 42 (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) 7 Method of test: Air 24c.For Water Supply&InjectiI nlWells: 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: 120Z completion of well construction tot the county health department of the county
-•• -• - where constructed. I
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-21)16