GW1-2022-03710_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver "14`WATER ZON
FROM TO I DESCRIPTION
Well Contractor Name 123 ft' 168 n'
3002-A fl. ft.
NC Well Contractor Certification Number
19)0 NER100 1 licable)
Carolina Well Drilling Val TO , I DIAMETER THICKNESS MATERIAL
Company Name 0 18 10 SDR21 PVC
J4&,IKNER CASIN 0,.01R.TUBING.(detitherinall aoset!4660)
2.Well Construction Permit#: 10012596 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) 0 r(' 44 rL 6 1/8" In. SDR21 PVC
3.Well Use(check well use): ft• ft. in.
r water Supply Well: FROM TO DIAMETER^ SLOT SIZE. THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. Ift. In.
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. Ift. in.
Industrial/Commercial [3Residential Water Supply(shared) r._18;'GROUT.�J zl'�!?,,I­,`,�
irrigation FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 18fL Bentonite Pour(12)501b Bags 10"
:3Monitoring DRecovery 20+ Bentonite Pour(14)501b Bags 6 1/8"
Injection Well:
n, Aquifer Recharge OGroundwater Remediation
19.SANDIG `PACK,if aiipllciible).­,
Aquifer Storage and Recovery [3Salinity Barrier FROM TO I I MATERIAL _I EMPLACEMENT METHOD
,]Aquifer Test [3S(on-nwater Drainage rt. ft.
:]Experimental Technology [3Subsidence Control ft. fL
:)Geothermal(Closed Loop) OTracer t10.,DRILLING, 3 G ettil additional sheets.If necessar
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO 1 DESCRIPTION(color,hardness,solitmck type,grain size,etc.)
0 16 n. Fill Dirt/Clay
4.Date Well(s)Completed:2-25-2022 Well ID# Well#2
18 26 Brown Clay/Rock
Sa.Well Location: 26 Granite
Epcon LR2 LLC fL ft-
Facility/Owner Name Facility ID#(if applicable) ft. ft.
16020 Headwaters Dr. Huntersville 28078 ft. ft.
Physical Address.City,and Zip
Mecklenburg 021-123-80 -I—TRK—RARKTI,777
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification.
35.39.756 N 80.77.396 W 3-17-2022
6.Is(are)the well(s)oPermanent or 13Temporary Signature ofrcrtified Well Contractor Date
By signing this form,I hereby certify that the it,ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or RNo with 15A NCAC 02.C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infonnatinn 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 diagran'I 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 I GW-I 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: 800 i
00 24a. For All Wells: Submit this form within 30 days of completion of well
For ninhiple wells list all depths if different(example-3@200'and 2@160D construction to the following:
10.Static water level below top of casing: 24 Division of Water Resources,Information Processing Unit,
If water level is above caring,use 1017 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Inoection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also sub�mit 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) 15 Method of test: Air 24c.For Water Supply & 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: 48oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016