GW1--05794_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
1
Frankie L.Oliver °'14.WATER ZONES ,i.,; , -
Well Contractor Name FROM TO DESCRIPTION
99 ft. 130 ft. f i
3002-A ft ft. I ,
NC Well Contractor Certification Number
-"15,OUTER CASiNG':(far multi-casedAvells)„OR I3NF.R(if ap licable)`. ,
Carolina Well Drilling FROM TO DIAMETER 1 THICKNESS MATERL4L -
0 ft. 84 ft' 61/41 in' SDR21 PVC
Company Name
»16.INNER�CA,SIN(;=OR TUBINf.;(gcothermal closed-loop)
10014007
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. i in.
1
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :'17.SCREEN .u... '- , " . ; , .'.`, ..
FROM TO DIAMETER 'S SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.'
Geothermal(Heating/Cooling Supply) Ea Residential Water Supply(single) it. ft in.
Industrial/Commercial DRe.sidenttal Water Supply(shared)
=_;18.
Irrigation FROM TO n MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(24)50Ib Bags
Monitoring DRecovery ft ft.
Injection Well: ft. ft. .
Aquifer Recharge 0 Groundwater Remediation
-19.SAND/GRAVEi:PACK(if applicable), -
' x
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stonnwater Drainage ft. ft. i,
1
Experimental Technology Subsidence Control ft. ft. I
Geothermal(Closed Loop) ElTracer 20.DRILLING:LOG(attach additional sheets if necessary),
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sod/rock type,teals size,etc.)
0 ft' 21 ft' Red Clay
4.Date Well(s)Completed: 8-14-23 Well ID# 21 ft' 50 ft' Brown Clay
5a.Well Location: 50 ft' 70 ft' Brown Rock
ft. ft. y i^ •'*.
Tracy Burdette 70 200 Granite � r- ;
Facility/Owner Name Facility ID#(if'applicable) ft. ft. "1 1....,
10919 Arlington Church Rd.Charlotte 28227 ft. ft. SEP 0 1 2023
Physical Address,City,and Zip ft. ft.
Mecklenburg 139-121-04 -'21.REMARKS.' 3`
ii
I.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la/long is sufficient) 22.Certification:
35.19.849 N 80.60.993 �, 1'
8-21-23
Q.,�Temporary Stgnatttre of Certified Well Contractor 1 Dace
6.Is(are)the well(s)MPermanent or
By signing this form,I hereby certfip thin the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Ill Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill nut known well construction information and explain she 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 j
200
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@)100') construction to the following:
10.Static water level below top of casing: 38 (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 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Air 24c.For Water Supply&Iniectil*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 t i the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016