GW1--05792_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver :14:WATER ZONES.,• ' 'K ', ' - -s.
Well Contractor Name FROM TO j DESCRIPTION
107 ft. 111 ft'
3002-A 163 ft' 238 [t' f
NC Well Contractor Certification Number 'l5.-OUTER''CASING(for multi-cased`wells)OR LINER(if ap lie./hie) - - . _
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 47 ft. 6 5/8 !in' .188 Galv.Steel
Company Name 16.INNER CASING OR TUBING'(geothermal closed-loop).: "`
2.Well Construction Permit II: 10013790 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO K., DIAMETER• SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. ft. is
IN Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
DIndustrial/Commercial DResidential Water Supply(shared) 7Ri GROUT•
Irti ation FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT •
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(23)50Ib Bags
Monitoring DRecovery ft. ft. ,'
injection Well: ft. ft.
DAquifer Recharge ElGroundwater Remediation ty SAND/GRAB FT',PACK(if applicable) .: .
EllAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test El Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) r''
FROM TO DESCRIPTION(color,hardness,soilhock type,grain size,etc.)
Geothemral(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 4 ft' Red Clay
4.Date Well(s)Completed: 7-7-23 Well ID# 4 ft' 40 ft' Brown Clay/Rock
5a.Well Location: 40 ft' 275 ft' Granite
Prasad Damodharan ft. rt. E�� _.. 9 /E
Facility/Owner Name Facility ID#(if applicable) ft. ft.
11145 William Porter Rd. Charlotte 28277 ft. ft. SEP 1 2023
Physical Address,City,and Zip ft. ft' Intxmaticn Pf:-c i /.11 1 1r,,
Mecklenburg 229-152-16 '21:REMARKS . _ ;•.',- .DWir^ n:; .- -,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
35.05.720 80.77.319 NW,
C 7-25-23
6.IS(are)the well(s) Perntanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: il Yes or RiNo 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 under#21 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 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: 275 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3L200'and 2@100) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water 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 tliis'form within 30 days of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 18 • Method of test: -_ A1r 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: 18oz 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
I Revised 2-22-2016
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