GW1--07925_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Frankie L.Oliver
FROM TO DESCRIPTION
Well Contractor Name
3002-A •
66,75 it 97 ft.
112 f` 170 f`
NC Well Contractor Certification Number 015.OUTER CASING(forauulti.cased wells).OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETERI THICKNESS MATERIAL
0 ft. 56 ft' 61/4 al' SDR21 PVC
Company Name 16.INNER CASING OR TUBING`•(geotherimal-closed-loop)- •• -
2.Well Construction Permit#: 10013987 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.IBC,County,State,Variance,etc.) fG fL in.
3.Well Use(check well use): ft. ft is
17.SCREEN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic • ft. ft. in:
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) fy ft, in:
Industrial/Commercial DIResidential Water Supply(shared) -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20+ f` Bentonite Pour(22)50Ib Bags
Monitoring ORecovery et. ft.
Injection Well:
ft. ft
Aquifer Recharge I0Groundwater Remediation
19.SAND/GRAVEL PACK or applicablee).
Aquifer Storage and Recovery oSalinity Barrier - FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStotmwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ,, -r
FROM TO DESCRIPTION(color,hardness,suvrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under 4121 Remarks)
0 f` 15 f` Red Clay
4.Date Well(s)Completed: 11-8-23 Well ID# 15 f` 42 f` Brown Sandclav
5a.Well Location: 42 f` 200 f` Granite
William R Homes LLC it. ft r^ rF
SFacility (ifapplicable) ft ft r •----'N..,•i�>t4 \/§_,j 1•
Facility/Owner Name ID# a licable :�
7421 Ann Smith Ln.Charlotte 28208 et. et
Physical Address,City,and Zip ft, ft.
II.REMARKS - ',, '- Ins`Gflr "`n1 - r r
Mecklenburg 113-321-23 �II—
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.10.554 N 80.59.536 W
G/� I. 11-21-23
6.Is(are)the well(s)RIPerinanent or OITetnporary 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: )jYes or MINo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 1/21 remarks section or on the back of this•form. I'
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: 200 I.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 2Q100') construction to the following:
10.Static water level below top of casing: 16 (ft.) Division of Water Resources,Information Processing Unit,
If 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) 6 Method of test: Air 24c.For Water Supply&injection Wells: in addition to sending the foot to
the address(es) above, also sub'mit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 12oz, 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 Resources Revised 2-22-2016