GW1-2022-07514_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor information:
t
Frankie L.Oliver 14.WATER ZONES.
Well Contractor Name �..� p;, f � FROM TO UESCHII1TION
3002-A ®�l1t
;E.J" R 238 et' 351
474
NC Well Contractor Certification Number " 1 q(�
p.l�r, Z = 2022 15.0[ITF.R'CASiNG(for multl-cased iyells)ORi,fNER,(if u Iicable)-;
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERUh
0 [t. 75 [t' 10 'n' SDR21 PVC
Company Name
10012736 D JaSOG 16.INNER CASING OR TUBING( eothen al doseddao '
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.I17C,County,State,Variance,etc.) 0 ft. 175 ff 6 1/4! SDR21 PVC
3.Well Use(check well use): ft. [t. in.
i'Irrigation
ater Supply Well: '17_SCREEN
pPy FROM TO DIAMETER SLOT SIZE THICKNFSS MATF.RIAT,
Agricultural [l Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) Yg,GROUT
FROM TO MATERIAL EMI-LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et• 20+ f' Bentonite Pour 22)50ib Bags (6"
Monitoring ®Recovery 0 50+ ft' Bentonite Pour 42 501b Bags 10"
injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVF;L PACK(if apWicablil
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMFL4CEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. [t.
Geothermal(Closed Loop) ®Tracer `20.DRILLING:LOG(attach additional sheets if necessa )
FROM TO DFSCRTPTION(color,hardness selllrock rain size etc.)
Geothermal(lieatin /Coolie Return) Other(explain under#21 Remarks
0 [c. 9 fl' Orange Sand lay
4.Date Well(s)Completed: 7-1-22 Well ID# 9 [t. 85 [t Brown Sandcla
5a.Well Location: 85 ff 165 ff Brown Sand/Grave
Stephen Field 165 ft' 600 ft' Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4010 High Ridge Rd.Charlotte 28270 [t. n.
Physical Address,City,and Zip
ft. ft.
Mecklenburg 227-084-19 21.REMARKS
County Parcel Identification Nu.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
35.50.241 N 80,46.124 W t!
7-13-22
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor ' Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well; [3Yes or JoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known ivell construction information and explain the namre of the copy of this record hat been provided to the well owner.
repair under#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 wel I
construction,only I GW-1 is heeded. 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: 600 (tt) 24a. For All Wells: Submit this forte within 30 days of completion of well
Fnr multiple wells list all depths if different(example-3(a1200'and 1(a1100� construction to the following:
10.Static water level below top of casing: 25 (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 Infection 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,ruvuy,cable,dues[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: 36oZ completion of well construction to the county health department of the county
where constructed. `
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016