GW1-2022-08471_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
228 fA 332 et'
3002-A It. rt.
398
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased wells)OR LINER( ap"lieable).
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 74 ft' 61/4,. in. SDR21 PVC
Company Name
10012108 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.
Water Supply Well: FROM SCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural CIMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 5aResidential Water Supply(single) et ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
lrt'1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour 43)501b Bags
Monitoring DIRecovery
Injection Well:
Aquifer Recharge E]IGroundwater Remediation
d9;SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG;attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) � Other(explain under#21 Remarks)
0 ft' 27 ft, Red Clay
4.Date Well(s)Completed:3-21-2022 well ID# 27 ft' 40 rL Brown Shale
5a.Well Location: 40 et' 425 ft. Granite
Jose&Milagro Bonilla
Facility/Owner Name Facility ID#(if applicable)
11223 Faires Rd.Charlotte 28215 ft. fL
Physical Address,City,and Zip ft. fL APR 2 6 2022
Mecklenburg 105-222-31 21.REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.15.498 N 80.41.261 W
4-7-2022
6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this fonu,I hereby certify that the ivell(s)was(were)constricted in accordance
7.Is this a repair to an existing well: nYes or E?No 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 tender#21 remarks section or on the back of this fonu.
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 1 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: 425 (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.)
Division of Water Resources,Underground Itjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131b.Disinfection type: 70%HTH Amount: 32oZ 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