GW1--05823_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor information: I 1
u l
Frankie L. Oliver ':14.WATER ZONES " ',a -
FROM TO DESCRIPTION
Well Contractor Name
82,93 ft' 97,108ft. 1
3002-A
114 ft' 132 ft' 139,186,228�
NC Well Contractor Certification Number `IS.OUTER CASING(for multi-cased well's)OR LINER(if an licable),
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
Cum an Name 0 ft. 43 ft' 6 1/4 I' '°' SDR21 PVC
p y 16.INNER CASING OR TUBING(geothermal closed-loo . --- , •
23-18
2.Well Construction Permit#: FROM TO DIAMETER THICKNESSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. .' in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER ; SLOT SIZE THICKNESS MATF.RTAL
DAgricultural IMunicipal/Public ft ft. in.
ir Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it, in.:
DIndustrial/Commercial E3Residential Water Supply(shared) 1R.GROUT •:: ' 1
I'1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(26)50Ib Bags •
Monitoring DRecovery ft. ft. . •
Injection Well: •
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable):"
Aquifer Storage and Recovery DSallnity Barrier FROM TO MATERIAL EMPLACEMENT METHODAquifer Test liI Stormwater Drainage
ft.
ft• ft.
Experimental Technology Subsidence Control It.
DGeotheunal(Closed Loop) 11 Tracer 20.DRILLING LOG(attach additliuital sheets if necessary) ';.
FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 8 ft. Yellow Clay
4.Date Well(s)Completed: 6-8-23 Well ID# 8 ft' 20 ft' Brown Clay
5a.Well Location: 20 ft' 34 ft• Brown Sand/Gravel ,.— .'"—5' r._("
Michael&Suzanne Devine 34 ft' 250 ft' Granite 4 �cL L /E )
Facility/Owner Name Facility IDll(if applicable) Pt. ft. S E 0 1 l
202 1
4514 Raymond Austin Rd.Waxhaw 28173 ft. ft. f
IftfOT ssa scn s�f •c: sra:rJ clr
ft. ft. ,
Physical Address,City,and Zip .i3V'CS i?„
Union 06-036-006E _zi.REMARKS
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:
34.95.170 N 80.67.042 W .
7-5-23
6.Is(are)the well(s)MPermanent or Temporary Sr ante of Certified Well Con actor I Date
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ig Yes or iSallo 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 it formation and eaplain the nature of the copy of this record has been provided to the'well owner.
repair under 1/21 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 INSTRUCTIONS j•
9.Total well depth below land surface: 250 (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@200'and 2@100') construction to the following:
1n.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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) For Injection Wells: In addt '
24b. ition 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) 30 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: 16oz
completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-20(6