GW1--07927_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
Frankie L. Oliver 1a.WATE1t ZONE$. 1-
FROM TO DESCRIPTION
Well Contractor Name
93 ft 101 ft
3002-A 112 ft 136 ft. 224 1
NC Well Contractor Certification Number :„15.OUTER CASING(for'utulti-cased,wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 83 ft 61/4 in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed=loop)• -
2.Well Construction Permit#: 10013887 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well compaction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. (ncompaction
3.Well Use(check well use): rt. f` in
Water Supply Well: FROM TO ' DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) j QiResidential Water Supply(single) fy it in-
IndustriaUComtnercial 01Residential Water Supply(shared) °,-18.GROUT-;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ ft Bentonite Pour(108)50Ib Bags
Monitoring jRecovery ft ft.
Injection Well:
ft. It.
Aquifer Recharge 0 Groundwater Remediation
,19.SAND/GRAVEL PACK(if applicable) , .. ' ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DSttnmwater Drainage It. It.
Experimental Technology OISubsidence Control ft. ft.
Geothermal(Closed Loop) COTracer 20.DRILLING LOG(attach additional sheets if necessary):, .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,suillreck type grain size,etc.)
0 ft 23 ft Red Clay
4.Date Well(s)Completed: 10-27-23 WellID# 23 ft- 65 ft Brown Dirt/Rock
ft. 225 ft
5a.Well Location: 65 Granite s-•� 'M. A•-`•?- ,
Dan Pop ft. ft. ' '` - ''.-0' _..t 1,• '4 -'
Facility/Owner Name Facility ID#(if applicable) ft ft. DEC
8935 Blair Rd.Charlotte 28227 ft rt. Z�L
Physical Address,City,and Zip 3
rt. rt. n• f,f.:•�iEsv 4~% k�4 Dfq
Mecklenburg 137-291-46 21,REMARKS ,, I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.11.370 N 80.38.315 W
11-1-23
6.Is(are)the well(s)EaPerinanent or OTemporary Si a e of Cerrifie well outractor Date
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or EINo with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standurdc and that a
If this is a repair,fill out known well construction information and eiplain 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,fonn. 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: 250 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(emmple-3@200'and 2@100) construction to the following: ,
10.Static water level below top of casing: 48 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1 61 7
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
.(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) 21 Method of test: Air 24c.For Water Supply&Iniel Lion 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: 70o/n 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 Resources Revised 2-22-2016