GW1-2023-02884_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD (GW-1) For Internal Use;Only:
1.Well Contractor information:
Frankie L.Oliver
Well Contractor Naive FROM TO UFSCRH'7fON
3002-A 63,70 rt• 149 ft.
182 rt' 218 11 n. 223
NC Well Contractor Certification Number '15L ORTi iR-CASiNCs'(foranulti'cased'Sveils)OR'.LINF.R"Ifii "licatiie)M
Carolina.Well Drilling FROM 'Ttl i DL"IETM TMCKNF-4S' MATERIAL
Cum auyNune 0 ft. 58 + ft. 6 1/4 to SDR21 PVC
P i16.:INNERXASING OR;.T
10013679 UBING`{ cotheriiial'closed•lati i .' ° F
2.Well Construction Permit#i: FROM ' TO DIAMETERTHICKNESS ' MATERIAL
List all applicable well constmedon permits(i.e.U1C,Cutmry,State,Variance,ata) EL
3.well Use(check well use): [I. [t. In.
l7iSCR15ENi"i, ?-.
Water Supply Well: FROM 1 TO i n1AMFTER Sl OTSIZE THICKNESS•cI MATERIAL
JAicultural DMunicipaMblic rl fa"
thermal(Heating/Cooling Supply) [3Recidential Water Supply(single) ft. 1m
ustrial/Cornmernial 13Recidential Water Supply(shared)
Irrigation FROM TO ! MATERIAL Fd1H'WCEMENTMETHOD&AMOUNT
Water Supply WWI,: 0 rt• 58 rt' Bentonite Pump(8)501b Bags
tritoriug Recovery et ft.
tion Well: ' ft. j a.
uifer Recharge Groundwater Remediation
;19.SAND/GRAYFT"PACK(if.. ltccdile "'
uifer Storage and Recovery [3Salinity Barrier FROM TO I ARTERIAL ]IMFI ACEMENT METHOD
uiferTeat oStonnwater•Drainageperimental Technology 13Subsidence Control ft. i ft•
othermal(Closed Loop) [3TracernFSCRTPTION(color hardness sotUrock rain sireeta)
othermal (Heating/Cooling Return Other(explain under 4121 Remarks)
0 ft. 31 n' Fill Clay
4.Date Well(s)Completed: 3-22-23 Well'ID#! 3 25 ft. Red Clay
Sa.Well Location: 25 ft. S� ft' Bow Sand r'-�- - r-�
Epcon LR2 LLC Well#4(#1 Meck.) 50 rf 225 n' Granite ',
Facility/Owner Name Facility ID#(it'applicable) ft. ft.
Courtyards @ Lawyers Rd.5810 Allen Black Rd.Charlotte 28227 It. a.
Physical Address,City,and Zip
Mecklenburg 197-062-08
County Paivel Identification No.(PIN)
'Casing full length pump grouted according to permit
5b,Latitude and longitude in degreeshuinutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification,.
35.80.533 N 80.37.326 w
�'� � 4-3-23
6.Is(are)the well(s)OPermanent or 13Temporary Signature of Certifit d Well Convector Dale
'B�•signing 11tis fort.I hereby certify that the well(s)was(were)conrirucled in accordance
7.Is this a repair to an existing well: [3Yes or JoNo ivith 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
lfthis&d repair,fill out hiow r well contiruclinn igfortnadon and explain the natwe of the copy of this record izav been provided to the well owner.
repair antler#21 renrarla section or on the back of thisfornt.
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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (it.) 24a. For All t'Vells: Submit this form within 30 days of completion of well
For multiple iveliv list all deptla if different(example-3@200'and 2 a(31001 construction to tee following:
10.Static water level below top of casing: 26 (M) Division of Water Resources,Information Processing Unit,
If water level it above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 2413.For Injection Wel(g: 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.)
Divisio of Wate
r Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 166 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 100 Method of test- Air 24c.For Water Supply&Irliection Wells: In addition to sending the form to
the addras(es)j above, also 'submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 18OZ completion of well construction to,the county health department of the county
where constricted.
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Form GW-I North Carolina Department of Environmental Quality-Divlsij'on of Water Resources Revised 2-22-2016
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