GW1--02203_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Well Contractor Information: ,I
1 1
Frankie L. Oliver 1$:fi'Atl`ER=.`,ONES ,ak.;- .c;xi!n _ til.;'^ %.,,* «„" s'.;�1,zc41-
Well Contractor Name FROM TO DESCRIPTION
fL fL
3002-A rt. ft
NC Well Contractor Certification Number :j]'5:OUTER4GASINGi(fotntbltl eusad'+':Wlls):QR LINER(if:upplicable) :1)4ra' -.
Carolina Well Drilling FROM TO , DIAMETER I THICKNESS MATERIAL
Company Name 0 ft. 43. II' 61/4 ,in' SD R21 PVC
23-294 =.:16i INNER'eASING)R TUBING;(geothermril closed loop) . ;'t vt;-..:•"k. ., ,
2.Well Construction Permit#: FROM TO DIAMETER' THICKNESS MATERIAL
Liu all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. ' I in.
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: ;';17.SCREEN >>�,,, k :,,;' .. ..,,.,z � :. s,:
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public ft. ft. in.'
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 1t. it, in.
IndustriallCommercial ;DResidential Water Supply(shared) 2111:,GROUT} ,y ft,. r,.1 ;.: :_:,, t �;ess^' ,',,;,vl,,'?- ,5,,:
'irrigation FROM TO' MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R' 20+ fa Bentonite Pour(23)50Ib Bags
jMonitoring , QRecovety ft. ft. '
Injection Well:
it. ft.
JAquifer Recharge IJGroundwater Remediation '
s19.=SAND/GRAVFL`PACK,(IfaUh4cable) 2i� r h,`,I so`.'s ,'
°Aquifer Storage and Recovery E3Salinity Baffler FROM ' TO MATERIAL EMPLACEMENT METHOD
3 Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology • oSubsidencc Control it. ft.
Geothermal
(Closed •
Loop) TracerdO DRILLING LOG(attach additintial sheets`if siecessar))11 a':>f ,. i,,,-.4 a ':ti.
FROM TO DESCRIPTION(color,hardness,sail/ruck type,grain size,etc)Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks)
0 ft- 14 ft- Red Clay
4.Date Well(s)Completed: 2-15-24 'Well ID# 14 iL 26 IL Brown Clay/Rock
5a.Well Location: - 26 It' 600 ft- Granite r-•, -.-, ,-. _„
Dustin Lowery it. is � d ,.`i' .
Facility/Owner Name Facility Di/(if applicable) ft. it.
5509 HB Starnes Rd.Waxhaw 28173 ft. rt. I' aPfi 0 0 2024
Physical Address,City,and Zip ft. It. Inru r 7r,r..:�') .,^ ,,7•R.:;.g f='
Union 05-024-001
21:.REMARKS;'y; }'„�:. a.',i i4 z'..,.^11., l - .>ti r4`vf..t71't(' i rs,i4rr,>);+
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:
34.83.229 N 80.68.276 `,l,
,(.� 3-15-24
6.Is(are)the well(s)aPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the ara(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or Eallo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair;fill out knownwell construction i,furnwlot,and explain.the nature of the copy of this record has been provided to the well Donner.
repair under N21 remarks section or on the back of this form. I
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 pagato provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may alga attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 600 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuthipk wells list all depths if different(eranrple-31&200'and 2®100') construction to the following: 1
10.Static water level below top of wing: 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Set i Center,Raleigh,NC 27 699-1 61 7
11.Borehole diameter: 6 _(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24u
Air Rotary above, also submit one copy ofkhis form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 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: 36oz 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