GW1--07926_Well Construction - GW1_20231208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information:
I .
Frankie L.Oliver 14.-WATER ZONES: r'.
FROM TO DESCRIPTION
Well Contractor Name
70,82 ft- 105 ft. 1
3002-A 112 fL 188 ft- 247,256,
NC Well Contractor Certification Number .15.OUTER CASING(for mtilti-cased+;wells)OR LINER(if applicable) e:
Carolina Well Drilling FROM TO DIAMETER! THICKNESS MATERIAL
0 ft' 63 ft. 6 1/4 .in. SDR21 PVC
Company Name.
16.INNER CASING OR TUBING(geatherival closed-loop).'
2.Well Construction Permit#: 10013872 FROM To DIAMETER THICKNESS MATERIAL `
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. 1 in
ft. ft. ! in.
3.Well Use(check well use):
'
Water Supply Well: FROM
x. F TO DIAMETER SLOT SIZE THICKNESS MATERIAL '
DAgricultural OMunicipaliPublic ft. ft. in.
0 Geothermal(Heating/Cooling Supply) j!jiResidential Water Supply(single) fL it. 1t.
DIndustrial/Commercial DIResidential Water Supply(shared) 18sGROUT,
Il Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ ft- Bentonite Pour(26)501b Bags
OMonitoring OIRecovery ft. ft.
Injection Well:
it. ft.
Aquifer Recharge 0Groundwater Remediation
`I9.SAND/GRAVEL PACK(if applicable)' - `' ..
0 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage et et
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) '° `-
Geothermal(Heating/Cooling Return) . f Other(explain under#21 Remarks) FROM TO 0 ec 6 ft DESCRIPTION(corer,hardness,soil/ruck type,grain size,etc.)
Red Clay
4.Date Wells)Completed: 11-10-23 Well ID# 6 rt. 20 ft- Brown Sand
5a.Well Location: 20 ft 50 ft. Brown Rock .
William R Homes LLC 50 ft. 300 ft. Granite
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Facility/Owner Name Facility 1D#(if applicable) rt. ft t�, . ,i. •`/ 1--- >
8828 Lynn Parker Rd.Charlotte 28208 ft. ft.
D
Physical Address,City,and Zip
IL H(fi8zez3
Mecklenburg 113-321-22 2t:,REMARKS,;, . : ,t-,,.,,
DWC5L93
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:
35.10.555 N 80.59.540 w
�- 2 ::, 11-21-23
)I Temporary Signature of Certified Well Coutractot1. Date
6.Is(are)the well(s)MPermanent or
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: II Yes or 'j!;!No 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#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: 300 (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(0100') construction to the following: '
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10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServicefCcnter,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,ronly,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) 27 Method of test: Air 24c.For Water Sunnly &injection Wells: in addition to sending the form to
the address(es) above, also sub`mit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 180z 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