GW1-2022-08461_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
162 ft• 169 ft.
3002-A
468 f t' 512 ft.
NC Well Contractor Certification Number ' 6.OUTER CASING(for multi•cased yells)OR LINER(if a lL ble).
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL w
Company Name 0 fL 80 fL 10 , ' SDR21 PVC
16.'INNER CASING OR TUBING(eothermal closed-loo
2.Well Construction Permit#: 10012109 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.171C,County,State,Variance,etc.) 0 ft' 140 fL 6 1/4 m. SDR21 PVC
3.Well Use(check well use):
Water Supply Well: '17.SCREEN �
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. i"•
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_- hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ec. 20+ ft' Bentonite Pour 97)501b Bags 10"
Monitoring ORecovery 0 ft. 20+ ft. Bentonite Pour(23)501b Bags 6 1/4"
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) `
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG{attach additional<sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 rt. 18 fL Red Clay
4.Date Well(s)Completed:3-7-2022 Well ID# 18 "' 106 rL Brown Sand/Gravel
5a.Well Location: 106 ft. 121 fc' Soft Granite
Jose&Milagro Bonilla 121 fL 650 ft' Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
11227 Faires Rd.Charlotte 28215 rt. ft. ."- _
Physical Address,City,and Zip ft. ft. APR 2 6 202?
Mecklenburg 105-222-32 21 REMARKS y
County Parcel Identification No.(PIN) �rra e�y °p�np'�fr�+�l�
!?:YtnClli�Nil l`RVLL�7mG U
5b.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.15.861 N 80.41.042 W
��- 3-17-2022
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, I hereby certh that the i ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 rentarks section or on the back of this fonn.
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 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: 650 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
If,vater 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) 1 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: 44oZ 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