GW1--00466_Well Construction - GW1_20240116

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WELL COINSTRUCTION RECORD(GW-1) For Internal Use Only:
' i
1.Well Contractor Information:
Michael A Brook
714:WATERZONES".'___-,., ...:-, ,
Well Contractor Name FROM TO DESCRIPTION
4210A 112 f• 116 fr• 5 gpm; •155 ft-5 gpm
fr. 135 ft. 5 gpm; 260 ft 10 gpm
NC WeILContractor Certification Number a•15.OUTER CASING.(for mtilti-cased;,wells OR LINER Wan hcahle
f P )
Rockwater Well and Pump Service Ind FROM TO DIAMETER I THICKNESS MATERIAL
0 it 104 f. 6.25 tin:
Company Name
:16.,INNER,CASING OR TUBING
2.Well Construction Permit#:
10014179 FROM TO DIAMETERherma THICKNESS) MATERIAL-
List all applicable well construction permits(i.e.UIC,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 (Municipal/Public 0 it ft. in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft.' ft in. ,
Industrial/Commercial DResidential Water Supply shared
PP Y(shared) 18:7GROUT ..
. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it• 20 ft• Bentonite 22 bags
Monitoring [Recovery ft. ft.
Injection Well:
Aquifer Recharge (Groundwater Remediation ft. ft.
-19.SAND/GRAVEL-PACK(if.applicalilc)` -
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) (Tracer 20:aRILLING•LOG(oftach additional Sheets if necessary'.) _ - '
Geothermal(Heating/Cooling Return) .'��Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,roll/rock type,grain size,etc.)
0 ft. 50 ft. red dirt '
4.Date Well(s)Completed:. 12/7/23 Well ID# 50 ft. 68 ft• tan dirt ff
5a.Well Location: 68 ft 90 ft. soft rick 1....4..
_
:;,it,^6, ,.1--it Vi -G i
Jacelyn Awender 90 ft. 112 ft. hard grey rock /6�L ti ('"'
ii
Facility/Owner Name Facility ID#(if applicable) 112ft. 116 ft• cave; JAN 1 Z024.
7540 Buckland Rd Charlotte NC 28206 116ft• 125 ft• tan rock lnforn74f 11,a Pr -.-;_
Physical Address,City,and Zip 125 ft. 145 ft. light grey,white rock DANci 30G t1�
_ Mecklenburg 113-302-29 amilmmip= •
County Parcel Identification No.(PIN) 145ft-165ft brown rock
165ft -320ft dark grey rock
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 1
6.Is(are)the well(s)DIPermanent or ((Temporary Si attire efCertified ontractor Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (Yes or (No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 321 remarks section or on the back of this forni. 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 I 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: 320 (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: I
10.Static water level below top of casing: (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 Infection Wells: In addition to sending the form to the address in 24a
air rotaryabove,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) 14 Method of test: air 24c.For Water Supply&Iniection Wells: In addition to sending the form to
15 lb the address(es) above, also submit one copy of this form within 30 days of
.
13b.Disinfection type: HTH Amount: 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