GW1-2023-02885_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well CuntcacWrNatne FROM TO DESCRIPTION
124 fc, 144 ft.
3002-A
189
NC Well Contractor Certification Number 15:OUTER'CASING(for mtilti-eksed4ells)OR LINER(if a usable)
Carolina Well Drilling FROM TO DLIMETER THICKNESS MATERL4L
Company Name
0 ft, 100 ft' 61/4' tn' SDR21 PVC
,
10012717 16:INNER CASING,OR TUBING(eothermal closed-loo),_
2.Well Construction Permit#• FROM TO DUMETER THICKNESS MATERIAL
List all applicable well consnuction permits(i.e.U1C,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 Si7.E. THICKNESS MATF.RTAT,
Agricultural E]Municipal/Public ry• p• in.
,Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Cotmnercial []Residential Water Supply(shared)
1R.GROUT
Ini ation FROM TO MATERIAL EMI'LACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 fc. 20+ «• Bentonite Pour(30)501b Bags
Monitoring Recovery ft. ft.
Injection Well:
_ Aquifer Recharge Groundwater Remediation 19.SAND/GRAVF.I PACK(if a 1(catile)'
Aquifer Storage and Recovery OSaliniry Barrier FROM TO 5UTERIAL EMI'L 4CEMENT METHOD
Aquifer Test [3Stormwatet-Drainage ft, ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary),..'
FROM TO DFSCRTPTTON(color,hardness soll/rock rain size etc)
�Geothermal(Hearin /Conlin Return) ' Other(explain under 421 Remarks) 0 ft• 10 ft• Red Clay
4.Date Well(s)Completed: 12-20-22 Well ID# 10 ft• 95 ft' Brown Sand/Gravel
5a.Weft Location: 95 ft, 200 ft• Granite
Christopher Hopkins ft. ft, :: - —_
Facility/Owner Name Facility IDH(if applicable) -
7204 Buckland Rd.Charlotte 28278 et. ft. APR 1 S 202.1
Physical Address,City,and Zip ft. ft.
Mecklenburg 113-302-35 21:REMARK4-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/ininutes/seconds or decimal degrees:
(if well field,one tar/long is sufficient) 22.Certification:
35.10.155 N 80.59.586 W
���(�� 1-18-23
6.Is(are)the well(s)JRPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our knoum Nell construction information and explain the nature of the copy of this record has beenprovided to the well owner.
repair tinder#21 remarks section or on the back of this farm.
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: 200 UL)
24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereut(example-3 a7200'wu12(a1100� construction to the following:
10.Static water level below to of casing: 57
p �� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above cashrq,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For htjectiou Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this;fann within 30 days of completion of well
12.Well construction method: construction to the following:
(ix-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) 7 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: 12OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016