GW1--00973_Well Construction - GW1_20240208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
223 ft- 240 it'
3002-A
ft. ft.
NC Well Contractor Certification Number A15.OUTER CASING`(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER . THICKNESS MATERIAL
0 ft. 84 ft- 6 1/4I in* SDR21 PVC
Company Name 16.INNER CASING.OR TUBING(geothermal closed.loop)2,_,> `
2.Well Construction Permit#: 23-56 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,Stale,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft ft. in.
17.Water Supply Well: FROM
SCREEN OMTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MI Residential Water Supply(single) fy ft. in.
Industrial/Commercial DIResidential Water Supply(shared) lA:GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Benton'ite Pour(27)50Ib Bags
Monitoring IlRecovery 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 DStotmwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additional sheets if necessary) : i.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
0 ft 7 ft Red Clay
4.Date Well(s)Completed: 12-21-23 Well ID# 7 ft" 68 ft. Brown'Sand/Gravel
5a.Well Location: 68 ft 250 ft Granite -�.
Donna Wilson it. ft a-:
r"`
Facility/Owner Name Facility ID#(if applicable) ft. ft
9303 Maggie Robinson Rd. Waxhaw 28173 rt. ft. FEB 6 s 2024
Physical Address,City,and Zip ft ft (ff►fafv4`sCre'1'P•C=• R:Uri
Union 05-186-027B 21.REMARKS ' - - .CvV+itf:JG
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:
34.83.251 N 80.79.039 `,1t
1-4-24
6.Is(are)the well(s)ElPerrnanent or DI Temporary Si a of Certified Well Contractor Date
By signing this•form. 7 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or Eallo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and captain the nature of the copy of this record has been provided to the well owner.
repair under 1/21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
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-3 00'and 2@1001 construction to the following:
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10.Static water level below top of casing: 36 (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 Infection 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.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 •
13a.Yield(gpm) 13 Method of test: Air 24c.For Water Supply &injection Wells: in addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 150z 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