GW1--00963_Well Construction - GW1_20240208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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t
Frankie L. Oliver 14.WATER ZONES - •
FROM TO DESCRIPTION
Well Contractor Name
3002-A 247 ft t
335 f
• ft ft. I
NC Well Contractor Certification Number ..15TOUTER..CASING(for multi-cased wells).OR LINER(if applicable)-
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 45 IL 61/4 in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)"
2.Well Construction Permit it: 23-231 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft' ft. 1n.
3.Well Use(check well use): ft ft. in.
17:`SCREEN ;.;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) Zi'Residential Water Supply(single) ft ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18:GROUT . '.`
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ ft' Bentonite Pour(24)50Ib Bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK.(if applicable) • .•'
Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. rt.
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach additional sheets if necessary)'.' ''
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft- 17 rt. Red Clay
4.Date Well(s)Completed: 11-9-23 Well ID# 17 ft- 20 ft" Brown Sand/Gravel
5a.Well Location: 20 ft. 400 ft' Granite =`"t• A
Martin Wynne ft it. t L, 'V/4.i5..
Facility/Owner Name Facility ID#(if applicable) ft It i �"'t
6825 Loblolly Circle Waxhaw 28173 Providence Pines#18 rt. ft
FEY � 0 2024
Physical Address,City,and Zip ft ft If�i 1Wr:'1 rl.'Cj„a 1 l lr4:
Union 05-066-037A 2I.REMARKS,`,. , ` . '. C"v•Ci,elOG,.� ' -
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: '
34.53.177 N 80.42.392 •
We.c
12-4-23
lnanent or OTeanporary Signature of Certified Well Contractor Date
6.Is(are)the well(s) Per
'lily signing this,form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EN. with 15ANCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and a.splain 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: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffferent(example-3@ 00'and 2@100') construction to the following:
10.Static water level below top of casing: 29 (ft-) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 I
(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.) 1
Division of Water Resources;Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276 99-1 63 6
13a.Yield(gpm) 6 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: 24oz completion of well construction Ito.the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016