GW1--05793_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information: 1,
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Frankie L.Oliver C 14:{VATER'ZONES}i t ";ii , Y',. ;+t. '.,r „rhea`° i, c'ti '' £4`,.
Well Connector Nunc FROM ' TO 1, I11 DESCItn ON • '
3002-A ' . 174 ft• 288, 1t.t• I '
, It. ` 1 ft. 1
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NC Well Contractor Certification Number 15:.OUTER CASiNG(for tiniltkihi `wells)OR'T;TNF;R:'(ifap itcalile)', n ,.° ; s?t'
Carolina Well Drilling FROM To 1 I I' DIAMETe"1,t, • THICKNESS MATERIAL '
0 ft. 96 1It. 61'/4. In. SDR21 PVC
Company Name w, -
'10013823 i.16.-INNER'CASINGOR',!TUDWG,(gt'otherinalclosed.loopr �. ,.1,- *i a` '
2.Well Constructlon Petmitfi: FROM' TO i I 1 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 'ft. " I Et. I in.
3.Well Use(check well use): • ft ' 1 ft. In
Water Supply Well: . ;417.SCREEN.tt .+i + 4 k.W~, --� , :y;.,; ,.... *s, ,fir
FROM TO t II DIAMETER SLOT SIZE THICKNESS MATF.RTAI.
X Agricultural OMunicipal/Public ft• if.j:b n • 'in ,
ig Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) i1. int •
X Industrial/Commercial ,Residential Water•Supply(shared) , l?
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•'._111;GROUT �,„l il ,: , S y` s .
:A Irrigation FROM TO 6 1 to MA _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well,: 0 ft.. 20+1 IT Benkinite Pour(36)501b Bags
X Monitoring ®Recovery ft. j 11ft. •
injection Well:
ft. ; 1:It.
X Aquifer Recharge ®Groundwater Remediution
i.19;`SAND/GRAVPL PACK:(if applihble), "`1-''.;'''?..----• '''''.',;
0•Aquifer Storage arid Recovery .jSalinity Barrier FROM TO 1 I:t MATERIAL EMPLACEMENT METHOD
Stnrmwater Drainage , , t• '
I'Aquifer Test rt. I"f
II Experimental Technology ;0Subsidence Control •ft. i ft. I
Ili Geothermal(Closed Loop) OTracer ;720,`DRILLING•L'OG fattacli additldnal:sheets ifneceasary)a s„ w ,. 4
FROM TO' I i' DESCRIPTION(color,hardness,sotlirock type,grain sire,etc.)
*Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks)
0 ft' 44 n' Red Clay
4.Date Well(s)Completed: 7-27-23 Well IDII 44 EL 90, n' Brown Sand/Gravel
5a.Well Location: 90 ft' 600 n' Granite
Jeffrey&Jennifer Rahrig 1' ,. y 1
Lir
Facility/Owner NameFacility IDtt(if applicable) f n' C
•8818 Bee Tree Circle Charlotte 28270 ft. :- rut. SE P 1_ �023
Physical Address,City,and Zip ft rt
in>` r,r,atrat s, `,:„,, ,n,
. Mecklenburg 227-084-03 l'21REMARKS ' ss°+:: t S'ya h qi • aE , `rq ro
County Parcel identification No.(PIN) i+
'5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
35.08.903 N 80.76.493 NV ��`''� �
1 ' '8-2-23
6.Is(are)the well(s) Permanent or Temporary
Signature of Certified Well Contracto- Date
By signing this form;1 hereby ceriif^that the well(s)was(were)con:ci acted in accordance
7.Is this a repair to an existing well: QYes or �No With 15A NCAC 02C.0100 or 15A 1�CAC'02C.0200 Well Construction Standards and that a
If this is a repair,fill out baron well construction information and explain the nature of the copy of this record has been provide to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram d#'additional veli'details:
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this p ge to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells •construction details. You may a so attach additional pages if necessary.
•drilled: SUBMITTAL INSTRUCTIO S
9.Total well depth below land surface: 600 . . (it.) 24a. For All Wells: Submit is form within 30.days of completion of well
For multiple wells list all depths([different(example-3[a12011'and 2(0100) construction to the following:
°10-Static water level below top of casing: •46 (ft.) Division of Water R lurces,Information Processing Unit,
If water level is above casing.use"+" 1612,Mall Servi Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In druon to Sending the form to the address in 24a
Air Rotary above,also suht'r one copy o this form within 30 days of completion of well
12.Well construction method: construction tothefollowing:
,(i.e.auger,rotary,cable,direct push,etc.) .'
Division of;Water Resourc ,-Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16 6 Mall Servi e Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 1 -Method of test: Air 24c.For Wafer!Su 1 &Jr ection I Wells: In addition to sending the form to
the address(es) a ove, Mao's binit one copy of this forth within 30 days of
13b.Disinfection type: 70%HTH Amount: 360z completion of.Well constructs to'the county health department of the county
where constructed:' 1
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Form OW-I North Carolina Department of Environmental Quality-Division fWaterRes roes: Revised2-22-2916
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