GW1--07922_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver =.14.WATER ZONES " < ' ;
Well Contractor Name FROM TO DESCRIPTION
3002-A 38,43 it. 72 ft.
144 ft- 183 ft. 195
NC Well Contractor Certification Number 335.OUTER CASING(for multi-cased.wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 35 rt. 6 1/4' 'n' SDR21 PVC
's16.INNER CASING OR TUBING'(geothermal closed-loop)'."
10013755
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. ft In-
ft3.Well Use(check well use): ft. in.
Water Supply Well: .`17_."SCREEN s . , ,,. RI
FROM TO DIAMETER" SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) jai Residential Water Supply(single) ft. it. in
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT- ..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(19)50Ib Bags
Monitoring DRecovety ft. ft.
Injection Well: rt. rt.
Aquifer Recharge I0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage rt. rt.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer d 20.DRILLING LOG(attach'additiaiialsheets ifnecessar ) ,. '
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(colur,hardness,soil/ruck type,grain size,etc.)
0 ft. 6 ft- Red Clay
4.Date Well(s)Completed: 10-24-23 Well ID# 6 ft. 9 ft. Brown Clay
5a.Well Location: 9 IL 16 ft BroWn.Rock
Oleg Davidov 16 ft. 225 ft. Granite
Facility/Owner Name Facility ID#(if applicable) i>" ft•
7932 Wilson Ridge Ln. Charlotte 28227 et_ ft. a„' ' s. "'
Physical Address,City,and Zip ft. ft. DR: J 8 21L3
Mecklenburg 139-042-11 z tc REMARKS
County Parcel Identification No.(PIN) !riiJT+f c�n �r `j �i6ili
"^v..
aY3,..;vim
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.11.226 N 80.36.409 `j,
11-20-23
6.Is(are)the wells) Pennaltent or I Teanporary Signature of Certified Well Contractor; 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: E Yes or 'INo with 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain 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 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: 225 (ft) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(ij200'and 2Q100) construction to the following:
10.Static water level below top of casing: 24 (ft.) Division of Water Resources,Information Processing Unit,
Tf water level is above casing,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 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 75 Method of test: Air 24c.For Water Supply &Injection Wells: In addition to sending the form to
the address(es) above, also subniitlone copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 15oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource; Revised 2-22-2016