GW1--06789_Well Construction - GW1_20231024

i. ,
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver .:14:WATER ZONES; :_ .f
FROM TO DESCRIPTION
Well Contractor Name
3002-A 122 ft 174 ft 1 I
243 ft 274 ft 7
1,394
NC Well Contractor Certification Number 15.OUTER CASING(foriuul easedwells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 51 ft. 61/4 rn' SDR21 PVC
16.INNER CASING OR TUBING(g eothermal closed-loop) . ' - ?.`
2.Well Construction Permit#: 23-110 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.INC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft et in
Water Supply Well:
FROM TO DIAMETERR SLOT SITE
THICKNESS MATERIALAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. n, ill-
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ f[. Bentonite Pour(25)50Ib Bags
Monitoring ORecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
.19.'SAND/GR/VEL PACK(if applicable):- .'r
Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStotmwater Drainage ft. ft. j,
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer '20.DRILLING LOG(attach additional sheets if necessary). _"
FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) IO[her(explain under#21 Remarks)
0 ft- 8 ft Red,Clay
4.Date Well(s)Completed: 8-31;23 Well ID# 8 et' 15 ft Brown Clay e
5a.Well Location: 15 ft- 500 ft- Granite "'.$, G' ,, a
-'^z.•.s
Andrea Guzinski (Guzinski LLC) ft. ft. OC r 9 .:fu f ZC23
Facility/Owner Name FacilityID#(if applicable) t w
2618 Waxhaw-Marvin Rd. Waxhaw 28173 fr. ft 4 ry' r ,,r,
Physical Address,City,and Zip ft ft � z
w E II..REMARKS .,. E ,.
Union 06-210-059 . e ,T -
County Parcel Identification No.(PIN) I'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ,
35.58.002 N 80.47.569 W __C._,__>st/ 9-19-23
6.Is(are)the well(s)MPerrnanent or .Temporary Signature of Certified Well Contractor; Date
by signing this form. 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or ZjiNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/mama 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:
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 500 (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@i00') Construction to the following: I
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Iniection 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'
(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) 11 Method of test: Air 24c.For Water Supply&Iniection 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: 30oZ 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