GW1--02229_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver t44ah1'A'1'ERiZONE5` v:r:s` 1. :,Wi i, _."-.a s, :,',; ,9. ',rr:d>:, (3 -- ?I,.
Well Contractor Name ! FROM TO' DESCRIPTION
3002-A 1 88 117 ft.
221 ft. ft.
NC Well Contractor Certification Number PAS (IUTER:CASINGIf irYnultl.casedVellsTOR",LINlER`.(tf:appllcabIC) ii i'i
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 rt• 57 rt. . 6 1/4l I"' SDR21 PVC
6 16-INNER'CASING.(OR.TUBING�(geotherinal clo3ed-loop),: o _
2.Well Construction Permit#: 24- 6, FROM TO: - DLiMETER ! THICKNESS MATERIAL
List all applicable Hell cmrsinution permitsl(i.e.U1,C,County,State;Variance,etc.) !'t. ft. 1 ; In.
3.Well Use(check well use): 1 ft. ft. 1 in.
Water Supply Well: 17S'SGREEN ';,)i ? ''S•, )' ,6 t ,�.., _:.:' 4 _ .7:';, , 7,a F
FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
Agricultural UMunicipal/Public ft. ft. in l
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL g in.!
Industrial/Commercial DResidential Water Supply(shared) 1')k:tGROUT: „li:" niry �� t„" .; r r r.+,;t;, :,,,. s� k
Irrigation FROM TO. MATERIAL E1tfPR ACEMEN METHOD R AMUUNT
Non-Water Supply Well: 1 0 - 20+ Bentonite Pour(11)50lb Bags
Monitoring ; DRecovery fa ft.
Injection Well: 1 [t rt. i
Aquifer Recharge UGroundwater Reurediation
t19 SAND/GRA;V.EL"PACI('(If aUPltcablc)E <<.i s .; i _.y;; :ia+' �'. �r
Aquifer Storage and Recovery USalinky Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ustormwater Drainage fa ft.
DExperimental Technology Subsidence control p- rt.
i. •
9
Geothermal(Closed Loop) Tracer
Geothermal(Heating/Cooling Return) nOther(explain under 421 Remarks) e20 15R1LiiING IIl)G'(attach addiiioi ul sttects it tit cessary) * -;t r. r
FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
0 ft- 6 n• Brown Clay
4.Date Well(s)Completed: 3-13-24 Well ID# 6 rt. 25 rt. Brown Dirt/Rock
5a.Well Location: 25 ft. 250 R Graniteft.
r rt-
Tanner Design&Build ft. 1. C y + ;; i 1.r--3
Facility/Owner Name Facility IDi!(if applicable) tit. ft.
5111 Tom Stames Rd.Waxhaw 28173 Wildwood Reserve#8 n- fL ILA 'F O.' L51 L4
Physical Address,City,and Zip rt. rt. U i
Union .05-020-001T '' nra,� w .q,. ^r r ,�� o ,..,.
r21'.REMARKS:��'�t.' r , ,+ < Cri•tu. •1.1t ;;,
ii
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:
1;
34.88.673 N 80.66.448 `i, ;
.j�?�, ; 3-21-24
6.Is(are)the well(s)10Pennanent or Temporary Signature of Certified Well Con/tractor Date
By signing this,form.1 hereby cerr{fy fiwt the well(s)has(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infornatiun and etplain 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 farm. 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 necessazy.
drilled: SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 250 (rt,) 24a. For MI Wells: Submit this form within 30 days of completion of well
For nat/lipk welt list all depths if different(example.3@.200'and 2@100) construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+".. I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (ht.) 24b.For Injection Wells: In addition to sending the form to the address in 2Aa
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.) j ' •
Division of Water Resources Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: , Air 24c.For Water Sunray&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: 1 160Z completion of well construction to;the county health department of the county
where constructed.
North Carolina Department ofEnvironmental alit Division of Water Resources Revised 2-22-2016
Form GW-1 PQuality-