GW1-2022-09599_Well Construction - GW1_20221021

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
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rankle L.Oliver ,.14:-WATER ZONEs.
Well Contractor Name
FROM TO DESCRHITION
3002-A 55,58 f`' 64,78
138 f`' 161 f`' 184 211
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased`wells)OR ill,
INER(if a' lieable)'
Carolina Well Drilling FROM T(t DIAMETER THICKNESS MATERLAL
Company Name
r`' 61/4 '"' SDR21 PVC
10012498 A&INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coumv,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN ­1111
FROM TO DIAMETER; SLOT SIZE. THICKNESS MATF.RTAL
Agricultural []Municipal/Public ft. ft.
Geothermal(Beating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
_ Industrial/Comrnercial 13Residemial Water Supply(shared)
18.GROUT
h7i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT—
Non-Water Supply We �s 3 0 f`' 20+ ft. Bentonite Pour(9)501b Bags
Monitoring rj 11� Recovery ft. ft.
injection Wells q 1 ` ft. ft.
Aquifer Recharge OC\ L 1 dwater Remediation
79:SAND/GRAVEL—PACK(if a lictible).'
Aquifer Storage and Recover#j1 Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
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Aquifer Test ft. ft.
_ q `P4 tj� �StonmwaterDrainage
_ Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional'sheets if necessary)I`-
FROM TO DFSCRTPTTON(color,hardness soiltrock ratn size etc)
Geothermal(Hearin /Coolie Return) `Other(explain under#21 Remarks)
0 f`' 7 f`' Red Clay
4.Date Well(s)Completed: 8-30-22 Well ID# 7 ft' 36 n' Brown Dirt/Rock
5a.Well Location: 36 ft. 225 n. Granite
Bridwell Homes
ft. ft.
Facility/Owner Name Facility ID#(it applicable) ft. ft.
15017 August Ln. Charlotte 28227 ft. ft.
Physical Address,City,and Zip
ft. ft.
Mecklenburg 139-128-16 �21:REMARKS o
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/Ininutes/seconds or decimal degrees:
(if well field,one lathong is sufficient) 22.Certification:
35.13.196 N 80.36.298 W ✓j��
" 9-26-22
6.Is(are)the well(s)IOPermanent or UlTemporary Signature of Certified Well Contractor Date
k,signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eiristing well: ®Yes or WNo with 15A.NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill our kttriwn well cnnutructinn information and explain the nature of the copy of this record hae 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 wel I
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: 225 (ft.) 24a. For All Wells: Submit this 'form within 30 days of completion of well
Fnv multiple wells lift all depths ifili ferem(example-3@a 200'and 2L100� construction to the following:
10.Static water level below top of casing: 13 (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
(i.e.auger,rotary,cable,direct push,ut 12.Well construction m construction to the following:
ush,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) 11 Method of test: Air 24c.For Water Supply&Inlection 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: 15o2 completion of well construction to'a 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
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