GW1-2023-02886_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 44 WATER,ZONES-
FROM TO ` DESCRH'TION
Well Contractor Name 170 fL 206
3002-A
247
NC Well Contractor Certification Number A5.OUTFB EASiNG(for fimlli-cased wells)OR LINER up livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATE Eat
Company Name 0 ft' 106 ft' 61/4 run' I SDR21 PVC
16.INNER CASING,OR TUBING:( eothermal closed-loop),
2.Well Construction Permit 4: 10013559 FROM TO DIAMETER THICKNESS MATERIAL•
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): [t. [t. in.
Supply Well: 17.SCREEN
Water Su
pP FROM TO DTAMFTF.R SLOT SIZE THICKNFSS MATF.AiAi,
Agricultural []Municipal/Pablic it. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared) 71S.GROUT
IIrI ation FROM TO MATERIAL EDH'LACEbIENT METHOD&AMOUNT
Non-Water Supply Well: 0 et• 20+ rut' Bentonite Pour(it)501b Bags
:)Monitoring []Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAW..hPACK(if applicable)
Aquifer Storage and Recovery '®Salinity Barrier FROM TO MATERIAL EM CEMENT METHOD
Aquifer Test []Stormwater Drainage
ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer "120.DDRILLING TO
dS
LOG additional
sheets
if hardness,sonhock grain size
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) eta)
0 ft. 17 ft, Red Clay
4.Date Well(s)Completed: 3-17-23 Well ID# 17 ft' 98 ft. Brown Sandcla
5a.Well Location: 98 ft. 250 ft' Granite __ -
Slate Building Group LLC ft. ft. ;. ,,,•E-' c s a
Facility/Owner Name Facility ID#(if applicable) ft. [t.
10314 Buccaneer Rd.Charlotte 28227 `
Physical Address,City,and Zip ft. ft. IriiGs -:'.C'1 i�r ;•:�"^..;::� i�t;
Mecklenburg 139-272-09 ;21.REMAR%S
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la bong is sufficient) 22.Certification:
35.11.306 N 80.35.41.2 W (= 1
4-3-23
6.Is(are)the well(s)OPermanent or []1 Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or RNo with 15A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Consintction Standards and that a
If this is a repair,fill out knaim well construction itiffinnation and explain the nature of the copy of this record has heen provided to the well miner.
repair tinder#21 remarks section or on the back of this forth
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: 250 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Por multiple wells list all depths if different(example-3L200'aru12(a)100� construction to the following:
ill.Static water level below top of casing: 71 (ft.) Division of Water Resources,Information Processing Unit,
If seater level is above casirt,S,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 m g:construction to the following:
(i.e.auger,rotary,cable,directctC 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(gpin) 9 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: 16oZ completion of well construction to the county health department of the county
where constructed.
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016