GW1-2022-09610_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use(Qajy:
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1.Well Contractor information:
t
Frankle L.Oliver
FROM TO DEscanrrlON
Well Cuntrattur Name 103 f`• 111 ft.
3002-A
NC Well Contractor Certification Number 209 f t. 307 f t' 313 f
1s OUTIi61t1GrASiN4 rst ritutii� a' t 9R >yNF is ;f ` 114-bi ., .
Carolina Well Drilling FROM TO DIAMETER TmcxN>vs MATMkL
Company Name 0 ft. 64 ft- 6 114 In' SDR21 PVC
10012433 0IMM"SINc R ti tli✓r -xsr + :,. .. i.'
2.Well Construction Permit#- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cownuctlon permits(i.e.U1C,Coangy,State,Variance,etc.) ft. ft. It].
3.Well Use(check well use): ft. n. in.
Water Supply Well: "48GRE
FROM I TO nrAMFTFR, Si.OTS17.E I THICKNESS MATF.RiAT.
Agricultural ®Mur icipal/Public tt iL is
Geothermal(Heating/Cooling Supply) EpResidential Water Supply(single) n• i tn,
Industrial/Commercial ®Residential Water Supply(shared) :r18 CRt)UT '
Irrigation FROM TOy I MATERIAL Fd11I'LACF-hI1II•t'rMETHOD&AMOUNT
Non-Water Supply WeAto t 0 ft• 20+ n' Bentonite Pour 12.5 501b Bags
Monitoring `.-�`'� Recovery ft. ft.
injection Well: (, 06 ft. ' ft.
Aquifer Recharge ater Remediation
Aquifer Storage and Recove r pt Salinity Barrier FROM TO I MATEPJAL I EMPULCWM NTMETKOD
Aquifer Test Iidiot p rj� ja Stormwater•Drainage rt. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®Tracer .2030ItTT2i)TN.R`] 6itaclt"ald8diiiil` eets,tru3s9 ? a e I z k
FROM TO nFSCRTPTiON color,hardnev sotl/roek ruin slu etc
Geothermal axiom Coolin Return) Other(explain under#21 Remarks
0 f`• 9 { f`' Red Clay
4.Date Wells)Completed: 9'9'22 Well ID# 9 ft' 37, n' Brown Dirt
37 ft. 55 5a.Well Location: Brown
Bridwell Homes 55 n' 325 n' Granite
Facility/Owner Name Facility IDN(it applicable) A. ft.
10920 Layton Place Charlotte 28227
ft. n.
Physical Address,City,and Zip
Mecklenburg 139-128-01 i;;21:?R1El�I 5.,, y. ;�P •t4, .* + ;t.
County Parcel Identifrcadon No.(PIN)
5b.Latitude and longitude in degrees/nilnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification•
35.13.197 N 80.36.338 W 9-26-22
6.Is(are)the well(s)OPermmment or Temporary
e of Certifie Well Contractor Date
By signing this farmil
1 hereby certify chat the well(s)KW(were)con irucied in accordance
7.Is this a repair to an eidsting Well' 13Yes or Jallo tviih 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill out bantm well cnnitructintt information and explain the nature of the copy of this reenrd*v been provided to the well gamer.
repair render#2)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 jback of this pageito 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: 325 (ft-) 24a. For All Wells: Submit this,fonn within 30 days of completion of well
For narLiple wells list all depth if deferent(cuunple-3(a)2l) •and 2 aO100) construction to the following:
10.Static water level below top of casing: 16 A) Divislott of Water Resources,Information Processing Unit,
If water level is above casing,use '+" t 6 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in-) 24b.For In ecti n Wells: In addition to sending the form to the address in 24a
Air Rotary above,also subs it one copy of this form within 30 days of completion of well
12.Well construction method: construction to !e following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of later Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 6 Mail Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) 23 Method of test: Air 24c.For Wate SuuDlv At I ecti 1 n.Wells: In addition to sending the form to
the address(es) bove, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 22o2 completion of Oell construction to!the county health department of the county
where construct
Form GW-I North Carolina Department of Environmental Quality-mvirudn of Water Racourcec Revised 2-22-2016
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