GW1--06792_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
i
Frankie L.Oliver '14.WATER ZONES: , 4€"'^' ,;;
Well Contractor Name FROM TO DESCRIPTION
174 ft' 265 ft' I '
3002-A
ft. ft.
NC Well Contractor Certification Number
,;15.OUTER CASING(for multi c'ased`ivells)-OR LINER Of applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 48 ft' 6 1/4 ;tD' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geutlierinal closed-loop)',
2.Well Construction Permit# 23-114 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) fL ft. i°'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural •Municipal/Public ft. ft, in:
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fL R• in.
Industrial/Commercial Residential Water Supply(shared) I
IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(15)501b Bags
Monitoring ORecovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage
ft. ft. i
Experimental Technology 1111 Subsidence Control ft. ft. I,
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary),. :'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO D SCRIPTION(color,hardness,son/rock type grain size,etc.)
0 ft' 21 ft' Brown Clay
4.Date Well(s)Completed: 7-3-23 Well ID# 21 ft' 700 ft' Granite
ft. ft. t-,.
5a.Well Location: 1r
ft. ft.
The Meadows @ Weddington ,'g, 't j I V)
Facility/Owner Name Facility ID#(if applicable) ft. ft. OCT , '' 2`(�
ft. ft. 2.)
Ennis Rd./Hwy. 16 Waxhaw 28173 in.——';y,i:a,:,
Physical Address,City,and Zip ft. ft. ' r, ,.;,;,', ' 1_lf:,('
Union 06-153-282
21.REMARKS : "1 :._ ti
'° '
County Parcel Identification Nu.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i
(if well field,one lat/long is sufficient) 22.Certification:
34.99.421 N 80.76.539 W
7-28-23
6.Is(are)the well(s)MPermanent or EITemporary 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: it Yes or EtNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction it frnnuttion and explain the nature of the copy of this record has been provided ro the well owner.
repair under 1121 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,
9.Total well depth below land surface: 700 (it.)
24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3L200'and 2(a)100') construction to the following: i
10.Static water level below top '
of cas mS 38 (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 ,
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 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: 42oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016