GW1--05120_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 DESCRIPTION
3002-A 139 ft- 176 et'et. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL,
0 ft. 128 ft- 6 5/8 in. .188 Galv. Steel
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
24-102
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MAI'EKIAI. -
List all applicable well construction permits(ie.U1C,County,State,Variance,etc.) ft. rt. to
3.Well Use(check well use): ft. ft in.
I Water Supply Well: 17.SCREEN
mom '10 DIAMETER SLOT SITE THICKNESS MATERIAL
°Agricultural OMunicipal/Public ft. rt. in.
°Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) f1.. it. in.
°Industrial/Commercial DResidential Water Supply(shared) Di GROUT
°Irrigation FROM TO M:ITF.RIAL EMPLACEMENT METHOD at AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(72)501b Bags
°Monitoring °Recovery ft. ft.
Injection Well: ft. ft.
°Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery Salinity Barrier i ROM TO M 1TERIAI. EMPLACEMENT METHOD
0 Aquifer Test °Sttmnwata Drainage
It. ft.
°Experimental Technology °Subsidence Control ft, ft.
°Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION i color.hardness,suit/ruck type,groin size,etc.)
°Geothermal(Heating/Cooling Return) nOther(explain under#21 Rem at i
0 ft- 6 ft. Red Clay
4.Date Well(s)Completed: 6-3-24 Well ID# 6 ft' 23 rt' Brown Clay
5a.Well Location: 23 ft 108 ft Brown Sandclav/Rock
Teleo LLC (Craig Miller) 108 IL 120 rt- Fractured/Loose Granite _
Facility/Owner Name Facility ID1f(if applicable) 120 ft. 200 ft' Granite t,� . -�, - t 4._ _
9315 Simpson Rd. Waxhaw 28173 Meadowbrook Lot#8 rt. ft- `
Physical Address,City,and Zip ft FL +I 7
r
Union 05-078-012H 21.REMARKS
County Parcel Identification No.(PIN)
*Transitioned casing to PVC at surface level
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:
34.83.253 N 80.71.446 W
0�• 6-13-24
6.Is(are)the well(s)12Permanent or ['TemporarySignature of Certified Well Contractor Date
By signing this form.1 hereby certify that the nell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or 51No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out k,wwn well construction in(fornutioa and explain the nature of the copy of this record has been provided to the nrll owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprolle/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 (t'k) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3(a 200'and 2Q100) construction to the following:
10.Static water level below top of casing: 19 (ft-) 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 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.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 24 Method of test: Air 24c.For Water Supply &Infection 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: 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