GW1--00962_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver , 14.WATER ZONES -• ` ' ,
FROM TO DESCRIPTION
Well Contractor Name
3002-A 41 ft- 270 ft
391 ft- 420 ft.
NC Well Contractor Certification Number .15.-OUTERCASING(for multi.cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 22 ft- 61/4 in' SDR21 PVC
Company Name "16 INNER'CASING`OR TUBING'(t;eothermal closed-loop)
2.Well Constrdction Permit#: 23-20 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft ec in
17 SCREEN ^.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OJ Muuicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) yiResidential Water Supply(single) ft. it. in.
Industrial/Commercial 0 Residential Water Supply(shared) 1R GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- Z0+ ft- Bentonite Pour(10)50Ib Bags
Monitoring i Recovery ft. et.
Injection Well: et rt.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. et. ,
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 211:'IRILLING LOG(attach additional sheets if necessary): ' _
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) '
0 ft- 13 ft- Brown Clay/Rock
4.Date Wells)Completed: 11-13-23 Well ID# 13 ft- 500 ft- Granite
5a.Well Location: et ft
Rodney Fetters rt ft. E^-+ ...,a FT; r,,...�,
Facility/Owner Name Facility HA(if applicable) ft ft c i.)
7121 Tirzah Church Rd.Waxhaw 28173 ft. ft. FEB .0 8 2074
rt. ft.
Physical Address,City,and Zip itT3v rms"':�.371
Union 05-104-012A .21.REMARKS.' . . .. M`' ',�4t...
County . Parcel Identification No.(PIN) _ __ -. —•
- -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '
34.83.433 N 80.73.070 `,l,
12-4-23
6.Is(are)the well(s)0Permanent or DTelnporary Signature of Certified Well Contractor Date
By signing this fort, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JJYes or Zi No 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 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.
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: 600 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths if different(example-3@200'and 2®100') construction to the following: i
10.Static water level below top of casing: 24 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+„ 1617 Mail ServiceiCenter,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.) i
Division of Water Resources!,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 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: 300Z 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 Resour les 1 Revised 2-22-2016