GW1--05119_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DF.iCRH'TIUN
3002-A 180 ft- 280 ft.
286 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER _ THICKNESS MATERIAL
o ft. 98 ft 6 1/4 l"' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 24-04 Fit/FM 10 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.U1C,County,State,Variance,etc.) ft. R. In.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM "I0 DIAMETER SLOT SIZE THICKNESS MAT F.RI U.
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 5aResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ ft. Bentonite Pour(27)50Ib Bags
Monitoring DRecovery ft. rt.
Iiijectlon Well: rt. rt.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
kquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStotmwater Drainage rt. rt.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION!color,hardness,suit/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft 18 ft. Red Clay
4.Date Well(s)Completed: 4-2 6 24 Well ID# 18 ft. 81 fL Brown Dirt/Rock
5a.Well Location: 81 ft- 300 ft Blue Slate I
p
Duzach LLC ft. ft. `^ '••• :J
Facility/Owner Name Facility ID#(if applicable) it. ft- A U G 2 ?074
Nesbit Rd.Waxhaw 28173 ft. ft.
Physical Address,City,and Zip It. It.
Union 04-312-010B 21.HEN(.ARRS
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:
35.52.32 N 80.38.13 W
t 5-10-24
6.Is(are)the well(s)�Permanent or DTentporary F tore of Certified Well Contractor Date
By signing this fonn. 1 hereby cert{fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or SING with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Suardurd&and that a
.f this is a repair,fill out brown 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
9.Total well depth below land surface: 300 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For naltiple wclit list all depths if different(example-3(a200'and 2Q100') construction to the following:
10.Static water level below top of casing: 41 (n-) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inlection 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 27699-1636
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Suntoly &inlection 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