GW1-2021-02686_Well Construction - GW1_20210527

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information-
Frankie L.Oliver
FROM TO DESCRIPTION
Well Contractor Name
136 f1' 372 ft
3002-A
455 n' 472 n
NC Well Contractor Certification NumberS;GgtGt(51:Gt fUrwfnuld cased;tye7lg�QB i 1NER if`' licable r'<'
Carolina Well Drilling FROM TO DIAMETER THICKNESS I MATERIAL
0 a- 45 n' 6 V& I"' SDR21 PVC
Company Name
t'6dIVNER?GA5IFiG�OR`.-1!`[JBING?(egttteirrial,closed too F, "S �?;s ;,
2.Well Construction Permit ti: 10011924 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. n.• In.
3.Well Use(check well use): ft ft to
Water Supply Well: &FROM�E I To $ � DIAMETER jSLOTSIZE I THICKNESS MATERAAI.
Agricultural 13Municipal/Public 0 fL fl. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL In.
Industrial/Commercial Residential Water Supply(shared) 1KGRbUC 1.�'�­77777
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 M 20+ r`' Bentortite Pour 23 501b Bags
Monitoring Recovery ft. fL
Injection Well:
Aquifer Recharge E3Groundwater Remediation
Aquifer Storage and Recovery E)Salinity Barrier FROM I TO f4AMERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL ft.
Experimental Technology Subsidence Control n• ft.
Geothermal(Closed Loop) Tracer ,-'.2A:-pttiLT INO 1 UG`attach.addttiotiitaheels![.nebessar _. ,.r;
FROM TO DESCRIPTION(color hardness sollfroek 1 in size etc.
Geothermal(Hearin Coolin Return) Other(explain under tf21 Remarks) 0 ft 8 n- Fill C16
4.Date Well(s)Completed: 5-4-2021 Well ID# 8 ft' 37 M' Brown Dirt/Rock
Sa.Well Location: 37 fL 475 ti
' Granite
Steele Trojan LLC _ eq
Facility/Owner Name Facility IDN(if applicable) ft' [t' _�F: t
Trojan Dr. Charlotte 28273 n' rL
ft. ft. v
Physical Address.City.and Zip
Mecklenburg 199-243-12 751REMARKS ._, n
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lntllong is sufficient) 22.Certification:
35.90.591 N 80.58.700 W 5-12-2021
nature of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary Sig i
8y signing this•torn:,1 hereby certify that the artll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or Ballo with I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out known well construction hnformation and explain the nature of the copy of this record has been provided to the well onwner.
repair under#21 remarks section or on the back of ihis 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 details. You may also a
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wellsttach additional pages if necessary.
drilled: SSUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 475 (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@1001 construction to the following:
10.Static water level below top of casing: 18 (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Ccnter,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 100 Method of test: Air 24c.For Water Supply&Infection 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: 300Z completion of well construction to the county health department of the county
where constructed.
0
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources` Revised 2-22-2016
i