GW1--00970_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: '
Frankie L.Oliver . i4.WATER:zoN ,,,,t . _.. _ _
FROM TO DESCRIPTION
Well Contractor Name
61 f` 105 f` I
3002-A
115 ft 125 ft 208,211
NC Well Contractor Certification Number
15:OUTER;CASING(for muln coaled=.wells)'OR LINEW(if applicable)
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ftit'43 6 1/4 I in' SDR21 PVC
•
16.INNER CASING OR TuBING"(geothermal closed-loop),
2.Well Construction Permit#: 23-246 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in
17-SCREEN .. t . ` `',, y°
Water Supply ...
Well: FROM TO DIAMETER�� SLOT SIZE THICKNESS MATERIAL
Agricultural DJ Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Zil Residential Water Supply(single) fy ft. in.,
Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ ft Bentonite Pour(11)50Ib Bags
Monitoring ORecovery it ft.
Injection Well:
It It.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)- '.," `' '
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft rt.
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OTracer .`20.I)RILLING LOG(attach additional sheets if
Geothermal(Heating/Cooling Return) Other(explain under#2I Remaks) FROM TO DESCRIPTION(color,hardness,aml/ruck type gram size etc)
r
0 ft' 22 ft Brown Clay
4.Date Well(s)Completed: 12-18-23 Well ID# 22 ft 250 ft.
Granite
ft. It.
5a.Well Location: It. ft ' ����i�`� '" t
OPE Investments LLC �'
Facility/Owner Name Facility ID#(if applicable) it, it.
7612 New Town Rd.Waxhaw 28173 rt. ft FEB 2024
Physical Address,City,and Zip It. II intonraien PrC'zee"„ :°u Df-
21
Union 06-132-032
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:
34.98.917 N 80.75.322 W j
12-28-23
6.Is(are)the well(s)�Perinanent or Temporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certif}r that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Xi No with 15A 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 i
9.Total well depth below land surface: 250 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths if different(example-3t 200'and 2@100') construction to the following:
i
10.Static water level below top of casing: 35 (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
(1,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) 24 Method of test: Air 24c.For Water Supply&injecti Jn 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: 15oz 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