GW1--03591_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L. Oliver 14.WATER ZONES
FROM TO D1;SCRti71(1N
Well Contractor Name
3002 A 105 EL 117 ft'
157 ft 166 et. 173,191,197
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 27 ff. 61/4 In' SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed•loop)
24-22
2.Well Construction Permit*: FROM TO DI TIIICF KM-. MATERIAL
List all applicable well construction permits(ie.U1C,County,State,Variance,etc.) ft. ft. I o
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
llp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft.
ft.
it. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
()Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(15)501b Bags
Monitoring DRecovety ft. ft.
Injection Well: —
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO NI ATERIAI. EMPLACEMENT METHOD
quifer Test jStormwater Drainage fL I I'
Experimental Technology DSubsidence Control ft_ ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO I)INCRI I'i ION I color,hardon,s,soil/ruck type,grain size,eta.)
Geothermal(Heatin /Coolin Return) flOther(explain under#21 Remarksj
0 ft' 15 ft' Red Clay
4.Date Well(s)Completed: 4-26 24 Well ID# 15 rt. 200 ft. Granite
5a.Well Location: ft. ft. ',C`e L � JIE 0
Jeremiah Jones
ft. et.
Facility/Owner Name Facility IDtt(if applicable) ft. it. J U N 1 u~ 2024
9302 Richardson King Rd.Waxhaw 28173 Kings Gate#7 rt. It. t
Irtsrxic.Mf ,,�,eAt-9 Lka
Physical Address,City,and Zip ft. it. ryf.( 3 r +
Union 05-171-007D 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.90.612 N 80.78.343 W
- 5-2-24
6.Is(are)the well(s)�Permanent or OTemporary a of Certified Well Contractor Date
Hy signing this,form.1 hereby cert(fy that the NeU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or EiNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well eorutruction 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
9.Total well depth below land surface: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nutltipk wells list all depths if different(example-300'and 2Q100) construction to the following:
10.Static water level below top of casing: 38 (n.) 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 Wens: In addition to sanding 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) 21 Method of test: Air 24c.For Water Sunni,/ &inleetlon Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: 70% HTH Amount: 12oz 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