GW1--06727_Well Construction - GW1_20231024

' FT-Tint Form '
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: l
Scott M.Werley 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
1.0 ft. 5.0 ft. saraayru�Id '
3344-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
ECS Southeast, LLP 1
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
W M 0301315&SIP#70003159 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable svell construction permits(i.e.U/C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DIMunicipal/Public o ft. 5 ft. 2 in. o.010 sch40 PVC
Geothermal(Heating/Cooling Supply) ©IResidential Water Supply(single) ft. ft. in' i
Industrial/Commercial EtResidential Water Supply(shared) 18.GROUT i
Irrigation I FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
X Monitoring 0Recovery I ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.'SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 0 ft• 5 ft• #2 silica sand Pour
Experimental Technology 0 Subsidence Control ft. ft. 1
Geothermal(Closed Loop) ©ITracer 1 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock hype,grain sine,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft• 0.5 ft. tan coarse grained sand;moist
4.Date Well(s) 9/27/2023
Completed: Well ID#SB-03 0.5 ff 1 5 rt' gray coarse grained sand;moist
5a.Well Location: I ,•s ft. 5.0 ft. blueish gray claye sit With-in gr sagd;wet
Timothy Fridley N/A ft. ft. -- , _ i•,�i .;3
Facility/Owner Name Facility ID#I(if applicable) rt. ft.
9905 Statesville Road, Charlotte, 28269 ail.12 i' 2023
ft. ft.
Physical Address,City,and Zip ft. ft. In�,,,, s. 7„- - . .l i',fi
Mecklenburg 02509269 21.REMARKS `'`'„.'-t_o,-
I
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long in sufficient) I 22.C rtification:
35.356269 N -80.842170
9.28.2023
6.Is(are)the well(s)DPermanent or X®ITemporary Signature of Certified Well o tractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: 0Yes or ONO with 15,4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfthie is a repair,fill out known well construction information and eap/ain the nature of the copy of this record has been provided to the well owner.
repair under#21 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:°net') SUBMITTAL INSTRUCTIONS i
depth below land surface: 5'�9.Total well
(ft.
) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: l
10.Static water level below top of casing: 1.5 (ft.) Division of Water Resources,Information Processing Unit,
!joules level is above casing,use"+" 11617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b.For Injection Wells: In addit(n to sending the form to the address in 24a
hand auger above, also submit one copy of thisifomi within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 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: Amount: 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