GW1-2023-02882_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well.Contractor Naive
65 ft• 134 rt.
3002-A
138 ft' 190 It.
NC Well Contractor Certification Number 15.OUTER CASING(for mull-cased wells)OR LINER(if a liable
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERL4L
Company Name 0 ft. 52 ft' 61/4 in. I SDR21 PVC
10013496 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DLt)IETER THICKNESS MATERIAL
List all applicable well cunstuction permits(i.e.U1C,Cutmty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMFTF.R ST.OT 517F. THICKNPSS MATFRiAI.
Agricultural �Municipal/Pubhc fL «. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) f7. In.
lndustrial/Commercial Residential Water Supply(shared) IR.GROUT
Irrigation FROM TO MATERIAL EMI I ACF.A[ENT METHOD&AMOIJNi
Non-Water Supply Wdl: 0 n 52 n' Bentonite Pump(7)501b Bags
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
73 Aquifer Recharge OGroundwater Remediation 19 SAND/GRAVET,PACK(ifapplicable)
Aquifer Storage and Recovery O Sailnity Barrier FROM TO I M 4TERIAL EMPLACEMENT METItt ID
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology ®Subsidence Control rt. ft.
Geothermal(Closed Loop) ®Tracer 20,DRILLING LOG(attach additional sheets if necessary)
FROM TO OFSCRTl'TTON Icolor.hard item,sonhock( raln size etc.)
Geothermaleatin Coolin Return) Other(explain under f121 Remarks
0 et. 3 rt. Brown_Sandclay
4.Date Well(s)Completed: 2-10-23 Well JIM 3 ft' 30 n' Brown-San d/Gravel
5a.Well Location: 30 rt' 200 n Granite
Oleg Davidov
Facility/Owner Name Facility Ii]#(it applicable)
10509 Briarhurst Place Charlotte 28227 ft. n. APH 1 8 2023
Physical Address,City,and Zip
ft. ft.
Mecklenburg 139-115-22 21.REMARKS
County Parcel Identification No.(PIN)
Well Variance Permit#JMB2852
5b.Latitude and longitude in degrceshni nutes/seconds or decimal degrees:
(if well field,one lac/long is sufficient) 22.Certification:
35.12.374 N 80.37.152 W
��(•��� 2-28-23
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified well Contractor Date
By signing this form,I hereby certifj that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If thu is a repair,fill out binun well conaructinn infnrmatum and explain the nature of the espy of this record has been provided in the well nxwer.
repair under#2I 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 well
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: 200 (1t) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffrrent(exrunple-3(pf200'and 2@1001 construction to the following:
1.0.Static water level below top of casing: 10 (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 (inA 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 mt pu construction to the following:
(it.auger,rotary,cable,direct pushh,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 Sutmly&Iniection 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: 12oz 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

a ROY COOPER •Governor
c
t� NC DEPART MFNT OF KODY H KINSLEY•Secretary
HEALTH AND 11F LEN WOLSTENHOLME•Interm Deputy Secretary for Health
HUMAN SERVICES
MARK T BENTON•Assistant Secretary for Public Health
I n,-i,, of{'�Ihly linahh
t h1.i1L• 1\'atrr I'rolcctiort Branch
Dcccnlher 10. 2022
Southem Interior and Design Corp. Inr.
of..l' West Duncan Rd
Indian Trail.NC 2807U
Re: %pppoval NoAN1132852
Pn\ate \\ell Located Less 100* from a Sewage or Liquid-Waste Collection Transfer
Faeilit\ (Rule 15A NCAC 'C .0107(a)(2)(H)]
Propem location:
10509 Briarhurst Pl.
Charlotte. NC 28227
To Whom It May Concern:
On December 14. 2022. the On-site Water Protection Branch received\our request for a
variance from the Well Construction standards. Title 15A North Carolina Administrative
Code Subchapter 2C .0100. The request for a variance concerns a proposed%eater suppl%
well on the referenced property. The closest watertight sewer main is more than fifty feet
aNa-, from the proposed well but closer than the required one hundred feet. The well will
sere a single-family dwelling.
Specifically,the variance grants you permission to construct a water supply well at a
distance closer than the one-hundred-foot setback to a sewer line. Achieving the
setbacks µould be difficult given the challenges of the property.
Based ulxm information provided by the Mecklenburg County Health Department.
and the property owner, it is my finding that based upon current conditions as the site
exist today(as well as the current proposal for use of the structure)you meet the
conditions necessary for approval of a variance as specified by 15A NCAC .0118 (a)
(1)and(2). On that basis and if the following conditions are met, the requested
variance is approved:
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH
L,XATION 5605 Six Forks Road.Raleigh.NC 27609
MAILING ADDRESS 1642 Mad Service Center,Raleigh,NC 27699-1642
—ncdhhs gov • TEL [phone] • FAx [phone]
AN EQUAL OPPORTUNITY'AFFIRMATIVE ACTION EMPLOYER

1) The new water supply well shall he constructed of either PVC. steel,or galvanized
metal casing.
?) The well shall be located.1% lilt as possible from any part of a sewer line,depending
t.ipt►n 101cre the 1'.01 lip can artu.rll\ -.et up. will possibly encroach upon the 100foot
selback. hilt fit, ('lose) tharl 5111ec1.
%) A biz-Coll slructitun ntceting \\iih the Mecklenburg County Ilealth Department staff is
rcyuurtl tt?cnwic that life maximum possihlc distances are achieved.
al 1 \%ill be rcquircd it, have casing installed to a minimum o1'50 feet below land
surfacc aild Ill lict into bedrock. If bedrock is encountered at a depth greater than 50feet,
then casing, must extend 10 Icet into bedrock.
5) (irrut will he required the entire length of the casing from land surface into bedrock.
6) A drill bit with a diameter of a least one third greater than the diameter of the casing
must be used to drill the eased portion of the well.
_) Grout must be either pumped into place with the use of a tremmie pipe or pressure
method.
The granting of this variance is for the well location only. It in no way relieves the owner
or agent from other requirements of the North Carolina Well Const-urtion Standards
including.but not limited to the requirements in 15A NCAC 2C .011_i(b)to repair or to
abandon any well which acts as a source or channel for the migration of contamination.
This approval does not imply sufficient water quality. Further, the approval does not
relieve your responsibility to comply with any other applicable Federal. State. or local
laws or regulations.
If\uu have any questions regarding this variance, please contact meat (828) 713-3 335.
Siincerely,
John M. 'Brooks R.E.H.S,MS
2