GW1-2022-10620_Well Construction - GW1_20221122

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'WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Tnfo oration: i
t
Frankie L.Oliver 14>'NATEItZONFS+a* Ir.:.< ti5
Well Contractor Name FROM TO D1SCRII ON
3002-A 96 f1• 109
118 r1' 136 i a' 139 C I
NCWeIIContractor CeRificat!on Nuinber `:.K,OUT;FR'CASiNG(for;�nultictrse'' ;welli)' WidNF,R`(Wa Ileuble)r
Carolina Well Drilling FROM TO f F DIAMETER i: TMCKNMS- ' MATERLkL
Company Name 0 ft. 82 r1' 61/4 I" SDR21 PVC
10012432 16i INNER CASING OR TUBING' e6therival closed too r:. t Via '
2.Well Construction Permit it FROM TO 'I DIAMETER HI TCKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,Cwmr9,State,Variance_,etc.) ft. I I.
in.
3.Well Use(check well use): t I, ft. in,
Water Supply Well: ,t7:`SCREEN'
FROM TO I 1 DiANM—R SLOTSI7.F. I THTCKNFSS I AiATF.RTAT
Agricultural nMunicipal/Public ft. ilm In..
:Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) n• R• In.
Industrial/Comrnetcial E3Residential Water Supply(shared) r
]li:GROUT ..;;`t :i -'?' ', .., _ ra e:;: •a- f.',
I[rl orlon -FRONI r TO I MATERIAL - ENRI ACEMENT METHOD di AMOUNT
Non-Water Supply Well: 0 ft. 20;+ tt Bentonite Pour(35)501b Bags
Monitoring DRecovery ft. ft.
injection Well: fL t't.
Aquifer Recharge Groundwater Remediation
�1!:SAND/GRAYF1t
Aquifer Storage and Recovery ®Salinity Barrier FROM TO` i MATERIAL Ertl FL4CEMENT METHOD
Aquifer Test [3Stormtvater•Drainage ft.
Experimental Technology ,Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20;DRILI.ING>O'G'Igttitch'addlfioNmfslicets'ifaeccssary i ,r=+:st'a•i
Geothermal eatin /Coolie Return) Other(explain under#i21 Remaiks FROM To , DFSCRiPTION(color,hardness solthock 1 grain Slre ern
0 rt. 11 n. Red Clay
4.Date Well(s)Completed: 10-29-22 Well EN 11 r1' 65 n' Brown Sandcla
Sa.Well Location: 65 r1' 150 ft. Granite
Bridwell Homes r<' A. --$ V"'
Facility/Owner Name Facility ID#(if applicable) ft. [t.
10912 Layton Place Charlotte 28227 ft. n'
Physical Address,City,and Lip ft fl ; iYed t3 l Ttn
Mecklenburg 139-128-03
County Pavel Identifimaion No.(PIN)
5b.Latitude and longitude in degrees/udnutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification: ;
35.13.292 N 00.36.570
. ' 11-11-22
6.Is(are)the well(s)J@Perutanent or Temporary Signatbre of Certifi Well Contractor Date
By signing this form,1 hereby certify Am the wells)was(were)constructed in accordance
7.IS this a repair to au'existing well: Yes or WNo with 15A NCAC 02C.0100 or 15A NCAC 62C.0200 Well Construction Standards and that a
7fthis k a repair,fig our ktioup irell cnnsmiction it formation aim]explain the nature of the copy of this rcrordlhas been pmvided in the well axmer.
repair ender#21 renurr/p section or on the back of This form. ;A Site diagram or additional well details:
8.For Gee robe/DPT or Closed-Laap Geothermal Wells having the same You may use the back of this page to provide additional well site details or Wei I
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction detntls. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
s
9.Total well depth below{and surface: 150 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdif/erwa(exmnple-3(a3200'and 2@100D construction,to the following:
30.Static water level below top of casing: 28 A) Divis on of Water Resources,Information Processing Unit,
if water level is above casing.use..". 1 17 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 24b.For Infection Wells: In addition to trending the form to the address in 24a
Air Rotary above,also sub nit 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: t 636 Mail Service';Center,Raleigh,NC 276994636
13a.Yield(gpm) 40 'Method of test: Air 24c.For Water Suutdv&Infection Wells: In addition to sending the form to
the uddress(cs) above, also snbinit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oz completion of ell construction1.to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-DivN 10
n of Water Resourcac, Revised 2.22-2016