GW1--05795_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Otily:
11.Well Contractor information:
Frankie L.Oliver ;��14�WATERzoNEs 1, ��.4 ..I. a
\Veli Contractor Name •
FROM TO 1• 11` DESCRH' ION
ft. ;ft,
368 i
3002-A. ft. 1 fi. 1
NC Well Contractor Certification Number 1j1s;01.1TRR:CASiNG.lfoc:uiulti cnscyi wells)t)R`LINFR gran liculile} > *
Carolina Well Drilling FROM T(l ' i; DIAMETER; THICKNESS MATERIAL
Company Name 0 fi. 85 ' ,�t' 61/4 In SDR21 PVC
•
p 16:INNER CASINC,OR:TUDING.(¢cotheniial closed•loop)0,, a'A-v, `a'>z v
2.Well Construction Permit it: 10013924 FROM ' TO ! 1 i' DIAMETkR THICKNESS MATERIAL
List all Applicable well conshuction pelmets(i.e.f/1C Co:mry,State,Variance,etc.) It. ;it. Iu. .
3.Well Use(check well use):
ft. 'II. In.
Water Supply Well: 'LII7iSCREEN a,:�y '.. •.: of ';1,i ; ,: ...s T-.., , . -. , (:( 'c
FROM TO ' ( . DiAMFTFw'• SLOT SIZE THICKNESS MATERIAL
Agricultural *Municipal/Public it. ft.: in
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
tt fr. tr
Industrial/Comnercial (°Residential Water Supply(shared) i°ilil GROUT.' ';: ± i :, r.,. _ :,?-
u .t.i-:;.
Irrigation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20+;:It' Bentbhite Pour(31)501b Bags
Monitoring °Recovery ft. 4'ft.
injection Well: •
ft. ft. ,
Aquifer Recharge ®Groundwater Remediation
:'19 SANG/GRA,\!;r 1PACK Of applicable) 1„ k'..'',,;.!._'I, , . " 5 ..>t' ' .
Aquifer Storage and Recovery Salinity Barrier FROM TO. MATERIAL EMPLACEMENT METHOD
Aquifer Test `E3Stonnwater Drainage ft. ','ft.
Experimental Technology EDSubsidence Control ft. ' n.
i ..
Geothermal(Closed Loop) 0 Tracer "s,311:;bRILLING?T OGdnttecli addifttuni'sheels if necessary) r 1 i.,.,i: £-f.:, .g ki i
FROM TO' 1' DESCRIPTION(color,hardness,soWUrock type,Amin sire,etc.)
Geothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks) 0 n" 6 ItRe 1 Clay .
4.Date Well(s)Completed: 8-18-23 Well ID# 6 n. 25 n' Brown Clay . .
5a.Well Location: 25 ft. 73 ft' BroT I wn Sand/Grave ' Qom,,+.' \ E
Bernie Parsons 73 ft. 675 ft, Gr nite - ��
Facility/Owner Name . Facility IN((if applicable) ft. n. i ; S E P 0 1 2023
13407 Castleford Dr.Charlotte 28227 ft n' . _I I .
Physical Address,City,and Zip ft. R. Mier/BOG
Mecklenburg 195-081-53 21:-REMARK.s,, �,.. .V.:.A 4 a .,_ ''._, r,7`,s- E.';-ti.a i7, ;,: .,<;n
County Partel•Identificetion No.(PIN) l
5b.Latitude and longitude In degreeshninutes/seconds or decimal degrees: l
(if well field,one lat/long is sufficient) 22.Certification: 1
35.14.968 N 80.65.335 W
8-23-23
.6.Is(are)the well(s)elPerinalient or E3Temporamy signature of CutiSed}Vep Conuacl¢r j Date
By signing this form,I hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: DYes or [23No With 15A NCAC 02C.0100 or isA (N(plc 02C.0200 Well Construction Standards and that a
If this is a repair,fill our berm well construction information anti explain the nature of the copy of this record has keen pmvidll to the well owner.
'repair under/121 remarks section or on the back of this form. 23.Site diagram or addidonalj 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-I is needed. Indicate'TOTAL NUMBER of wells construction details. You may Aso attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 675 '(ft.) 24a.For AU Wells: Submit!this form within 30 days of completion of well
For nmiftiple wells list all depths if different(example-3(e200'and 2(,)a 100') construction to the following: j 1
I '
lo.Static water level below top of casing: 15 lit.) Division of Water 1esources,Information Processing Unit,
;water level is above casing,use'•+" 1617 Mall Service Center;Raleigh,NC 27699-1617
I.11.Borehole dtanieter: 6 '(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also Sebn"!it one copy of this form within 30 days of completion of well
'12.Well construction method: construction to the following:
'(i.e.auger,rotary,cable,direct push,etc.) : 1
• Division of Water Resoueees,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: '1636 Malt Set-VlIice'C nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: Air 24c.For Water.Suplily&Ifiiecltlon Wells: In addition to sending the form to
the address(es)i above, also ubmit one copy of this form within 30 days of
13b.Disinfection type:,70%HTH Amount: 40oz ` completion of well construe on to lthe county health department of the county
where constnleted.
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-Fo m 6W-1 North Carolina Department of Environmental Quality-Division of Water Re.ources; Revised 2-22-2016
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