GW1-2022-05596_Well Construction - GW1_20220614

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 44.WATER ZONES°, ,
FROM TO DESCRII'TION
Well Contractor Name
115 ft- 126 et'
3002-A 138 ft. 223 ft. 238 255 286
NC Well Contractor Certification Number ,15:OUTFR-CASiNG(for multi-easetlwells)OR i:1NER(if i livable) ,
Carolina Well Drilling FROM To DLAMETER THICKNESS MATERL�I
Company Name 0 fc. 63 ft' 61/4 in' SDR21 PVC
10012681 15:1NNER-CASING OR`TUBINC,; eo hertnal closed-too")3
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well curestuction permits(i.e.111C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.�SCREEN
FROM TO DIAMETER SLOT S17F Tin XNFSS MATFRTAT,
Agricultural ;Municipal/Public it. fL in.
:]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
_ `Industrial/Comrnercial [3]Zesidential Water Supply(shared)
I&GROUT
Irri ation FROM TO MATERLAL ENPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ ft. Bentonite Pour(24)501b Bags
Monitoring []Recovery ft. ft.
injection Well:
et. ft.
Aquifer Recharge Groundwater Remediation
;19.SAND/GRAV,F,-L PACK(if a licr[l le)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD h
Aquifer Test Smrmwater Drainage
ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20-DRILLING LOG(attach additional sheets ifnecessa ")';'1'�,
FROM TO DFSCRTPTTON(color,hardness sotlhock rain size etc)
`Geothermal(Hearin /Conlin Return) Other(explain under#21 Remarks)
0 ft. 10 ft' Brown Dirt
4.Date Well(s)Completed: 4-26-22 Well ID# 10 ft' 30 ft' Grey Sand/GrawL
5a.Well Location: 30 ft' 300 ft' Granite L �.
Kyle&Kathryn Benzing ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fl. - 22
14500 Rainbarrel Rd.Charlotte 28278 ft. et. Ir> of .m2i Pry .
Physical Address,City,and Zip ft. ft. LAIM18OG
Mecklenburg 199-342-06 21 REMARKS
County Patccl Idcntificativa Nu.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lac/long is sufficient) 22.Certification:
35.73.972 N 81.13.997 W
�Z� 5-14-22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Cemiied Well Contractor Date
By signing this form,1 hereby certify ihai the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or WNo with 15A NC.AC 02C.0100 or 15A ArCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction infornuition and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
8.For Geoprohe/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-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 multiple wells list all depths if differenu(example-3L20t1'and 2 l000 construction to the following:
10.Static water level below top of casing: 36 (ft.) 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 Wells: In addition to sending the forts 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 2 769 9-1 636
13a.Yield(gpm) 14 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: 18oz completion of well construction tb 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