GW1--00974_Well Construction - GW1_20240208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
:;14.;WATERZONES' °'` j' " . ' 'Frankie L.Oliver : ,,r.,a.: �� .. �'�:°e;
FROM TO DESCRIPTION
Well Contractor Name
3002-A 86 ft- 181 ft-
205 ft' 214 ft- 255 1 '
NC Well Contractor Certification Number :15.OUTER CASING.(for multi.cased'wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER' THICKNESS MATERIAL
FROM0 ft-
57 f L DIAMETERi + '"' SDR21 PVC
Company Name
23-322 `^16"INNER CASING'OR TUBING(Rebtliei•nial clased.loop)'.>-,, `°.
2.Well Construction Permit#: 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 ft in.
Water Supply Well: .FROM
'. , '- . ',i , .!
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agriculhual DiMunicipal/Public • ft. ft. in.'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft- it. in.
Industrial/Commercial QIResidential Water Supply(shared) •,
1H..GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft- Bentonite Pour(21)50Ib Bags
Monitoring DRecovety ft. ft.
Injection Well:
it. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) ' •
Aquifer Storage and Recovery ElISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft. •
Geothermal(Closed Loop) Tracer 20.DRILLING:•LOG'_(attach additional sheets if necessary) '.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 13 ft. Red Clay
4.Date Well(s)Completed: 12-20-23 Well ID# 13 ft. 50 iL
p Brown Clay ^-,t---.,}.�,,.,„`/'
5a.Well Location: 50 f� 300 ff Granite U`i l� E r
Greg Fadale rt ft FEB ,9 B 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft '
9308 Richardson King Rd.Waxhaw 28173 Kings Gate#6 ft. ft. lnorv:24F'n'P�s= Alf;4 Uirit3
Physical Address,City,and Zip
ft. ft. CWCi% OG
Union 05-171-007C :2I REMARKS,,, `
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:
34.86.136 N 80.44.396 i
�, C
' 1-15-24
6.Is(are)the well(s)0Pennanent or �Telnporary '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: )jYes or ONo 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 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: 300 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wclis list all depths if different(example-34;200'and 2@100) construction to the following:
10.Static water level below top of casing: 26 (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.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 2 7699-1 63 6
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13a.Yield(gpm) 17 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: 18oZ 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