GW1--02231_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
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Frankie L. Oliver t2c14 w:ATEi ZONES ', 4 ?., Sk i'.t m r.i ,,., :`0._ ., 4 , ..r. ",-.s
FROM TO DESCRIPTION Well Contractor Name 63 ft. 75 IL. f
3002-A 92 ft' 137 fa
NC Well Contractor Certification Number 05::011TER'.CASING,(fornitiltt-eased%ivelli)'ORLINER'.(ifr'ap Hostile)': :4 .,
Carolina Well Drilling FROM TO DIAMETERI i THICKNESS MATERIAL
Company Name 0 fa 56 ft- 6 1/4 fin SDR21 PVC
23-238 :16aNNERICASING:ORiTUBING(kentheriarirelii ed li 4._a r 6w x:,'-I: ,,
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well constructionpen»ils(Le. U1C,County,State,Variance,etc.) ft ft I'In.
3.Well Use(check well use): et et. I'in.
Water Supply Well: a';17 SCREEN A +w..,,'- :01 ;{v 'f.0 ., 4..,: ,,.,�tIW,:;. `;';, , if
FROM - TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ii Agricultural DMunicipal/Public ft. ft. in.
.11 Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) it. it, in.
a Industrial/Commercial DResidential Water Supply(shared) YN GROUT -Ia• ,m, r.t=r.=a1 ' x r' ,ah z . a. ;
$In"i•ation FROM TO MATERIAL EMPLACEMENT METHOD a AMOUNT
Non-Water Supply Well: 0 ft. {-et. Bentonite' Ppi. (11)501b Bags
•,Monitoring "[Recovery ft. ft.
Injection Well: ft. n. ;.
Aquifer Recharge OGroundwater Rcmediation
{•t9,iSAND/GRAVEDP.ACK:IIr apjilleablet , r'a-^,ga` _.h: At-S,
•Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Aquifer Test QStormwaterDrainage rt. 'n• j
Al Experimental Technology OSubsidence Control 'ft. ft- ;,
Geothermal(Closed Loop) OTracer I:2113)1tILLINGII0qtrittieh tiddttiuriatihecttlf neces iaty) U,.s:4:., „r'.,
INGeothermal(Heatin./Coolin:Return) pg.Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,suit/ruck type Grain nine etc.)
0 EL ft. Red Clay
4.Date Wells)Completed: 3'5-24 Well ID# 6 n• 25 IL Grey claw
5a.Well Location: 25 ft' 250 ft. Granite i•'?",. ;"�. - F:..-,
Jennifer Crawford ft. ft. a 4W:�1r J,� ;�• i
,Facility/Owner Name Facility IDQ(if applicable) ft, it A PR V ' 2024
918 Woodland Forest Dr.Waxhaw 28173 ft• rt. Q
IL
Physical Address,City,and Zip DINOf .'1t
Union 06-240-013 ,21 REMARKS a=,,t ,, �... r. <, _ . fi.. -..4 ;*):.:P> xw„ .,.:_t;
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County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.99.439 N 80.83.281 W
_ . 3-15-24
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6.Is(are)the wells) Permanent or �Tennporary Signature of Certified Well Contractor { Date
By signing this.form, 1 herein'cen(ry,that the well(s) was"(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EilNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill oat known well construction information and explain the nature of the copy of this record has been provided to?he well owner,
repair under//21 remarks section or on the back !!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 l
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9.Total well depth below land surface: 250 (it) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3 00'and 2g100') construction to the following: j,
10.Static water level below top of casing: 38 • (ft.) Division of Water Resources,Information Processing Unit,
Ifuntet.level is above casing,use"+" '1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (iu.) 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.) i
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Air 24c.For Water Supply &Tnjection Wells: in addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 1502, completion of well construction to the county health department of the county
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where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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