GW1-2022-10619_Well Construction - GW1_20221122

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WELL CONSTRUCTION_ RECORD (GW-1) For Internal UrejOnly:
1.Well Contractor information:
Frankie L.Oliver yd:71VATEFttZQNES _nix`''':ir ,xi -:b s v v r r y s'..; Y' ," m 42
FROM TO I DFSCRnInON
Well Contractor Name FROM
fL 137 i
3002-A
165 fr' 176 ' n. }
NC Well Contractor Certification Number l--.0 tTER.CASINV-4hinmtilti•castdivells`OR"1:LNFRr Ifa licable;''
Carolina Well Drilling FROM I To I I DIAMETER FTMCKNL4S MATERIAL
CutapanyNamc 0 ft 109; ft. 6114 in. SDR21 PVC
1k'1NNERCA$LNG'Q1t;T" ING:(iothertnalclmedlod")'Fe
2.Well Construction Permit fl: 10012431 FROM TO ! DIAIt1ETElt, TMCKNES.S MATERIAL
J iki all applicable well consmicdon permits(i.e.VIC,Cauir v,&ate..Variancc etc.) ft ft. `ln'
3.Well Use(check well use): ft. I ft. in.
• - �.1qs'"!SCREEN i•�:i',t1,..,..�':r =,ire, t e,3'�,::'): .4.;�:.i:€4 �Pi".�.. �'.�lr;�.� `b,e S=�wr's�t"`«
Water Supply Well: FROM TO 1 I niAMETER SLOTS17.F. TIHCKNRSS I MATRRLAL
i Agricultural 13Municipal/Public fL IfL is
Geothermal(Heating/Cooling Supply) BRecidential Water Supply(single)
Industrial/Conn»ercial [3Residential Water"Supply(shared) 1R'GROU T,.. �.t} ;�s, .e 4,s.,. x,7;s , ,;•::
IIIi anon FROM TO I MATERIAL EMPL.ACFAIENr METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 i ft Bentonite Pour(GO)501b Bags
Monitoring Recovery [t. ft.
t
Injection Well:
ft ft.
_ Aquifer Recharge Groundwater Remediation
v.19:"SAND/GRA'VF i+PACK:Qf"a'Itivble) .3..';4-.. n_? +i<*tea'"`,r`•7-r.:.,<,. .. �s��*%3.�-T
Aquifer Storage and Recovery ®Salinity Barrier FROM TO n MATERIAL E51PLACEMFNT NMMOD
Aquifer Teel OStonnwatex Drainage
fc. rt.
Eaperimerital Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20'DRIrrLING LOG'lattiich'additiimal sheets:if uccrssri`` n x`x:+_': s b .,:
Geothermal(Heating/Cooling/Coolie Return Other(explain under 421 Remarks) FROM TO ! nFSCRTPTLON color,hardness sotVrock rain size,etc
0 ft. 7 « Red Cla
4.Date Well(s)Completed: 10-31-22 Well IDlI 7 ft' 98 ft. Brown Sandcla /Gravel
So.Well Location: gg f' 200 f f Granite'
E 4
Bridwell Homes ft. tL. Icy� E V C—
Facility/Owner Name Facility IN(if applicable) ft. t1.
1,0904 Ley Iton Place Charlotte 28227 fc. n.
NO
Physical AJdress.City,ana Zip ft. ft. Fri£ 3r1�fC�r �J Unit
Mecklenburg 139-126-02
r21:REM:ilRKS u';hs- :.t:'S4'r -.','� �F� -� ,c�'ti� z�-�,�,:•J ". .,r, n ,tr`*�..,1
County Puivcl Identification Nix(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees,:
(if well field,one ladlong is sufficient) 22.Certification:
35.13.272 80.36.571 _ J�
N W i 11-11-22
6.Is(are)the well(s)JOPermanent or Temporary Signs a of CuvSed Well Contractor I; Date
By signing/his form.I hereby cinify ihai the well(s)was(cadre)cow1rucled in accordance
7.Is this a repair to an existtng well: [3Yes or Jallo rvidi 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consmiction Stiuidards and duo a
If this is a repair,fill nut,broilfi well cyinrtruclinn n farnwdon and explain the nature of the copy of lhii record har heen provided tn.the well nivner.
repair under#21 remarks section or on the back of this farm
13.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 l GW-(is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional gages if necessary.
drilled: SUBMITTAL ItVSTRUCTIONS"
1,
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple ivellc licr all deptlif iftfi ererir(ex4mple-3@200'and 2 100) ConstNbtion to the fallowing:
i
.1o.Static water level below top of casing: 27 A) Division of Water Res I roes,Information Processing Unit,
irwater L-vei is above cas6ig,iuse"t" 1617 Mail Serrtce Center,Rnleigli,NC 27699-1617
11.Borehole diameter: 6 (in.) 246.For Infection Wells: In addition to sending the form to the address,in 24a
Air Rotary above,also subinit one copy of this;form within 30 days of completion of well
12..Well construction method: construction to the following:
(i.e.auger,tutaty,cable,direct push,etc.)
Division of Water Resources,rUnderground injection Control Program,
FOR WATER.SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
28 Air 24c or Water Su i,
13a.Yield(gpm) Method of test: Supply&Injection Wells: In addition to sending the furor to
the address(es)l above, also submit'one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount; 12oz completion of well construction to jthe county health department of the county
where constructed.
Farm GW-I North Carolina Department of Enviropmental Quality-Division of WaterResourcas Revised 2-22-2016