GW1--00987_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
,
• 1.Well Contractor Information:
Frankie L. Oliver 14.WATER ZONES. . , " ''
FROM TO DESCRIPTION
Well Contractor Name 47,59 ft- 64,130et-
3002-A
• 249 ft' 288 ft' 293,315,318
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 43 rt. 6 1/4 i in' SDR21 PVC
10014091 16.INNER CASING-OR TUBING_(geothermal closed-loop)" .r
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.1I1C,County,State,Variance,etc.) 0 rt. 75 rt. 4 to SCH40 PVC
3.Well Use(check well use): ft et i in.
Water Supply Well:
17.SCREEN .
FROM TO DIAMETER J SLOT SEM THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) j!Q(Residential Water Supply(single) ft. it. in.
IndustriaUCommercial �IResidential Water Supply(shared) 18.GROUT ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(17)501b Bags(6")
Monitoring DRecovety 0 ft' 75 ft- Portland Pour(10.5)47Ib Bags(4")
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL,PACK(if applicable) _ - ,'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage rt. ft.
Experimental Technology OSubsidence Control ft. ft. .
Geothermal(Closed Loop) OTracer 20.DRILLING DOG(attach additional sheets.if necessary'), : - ,'„, _
_ Geothermal(Heating/Cooling Return) fIOther(explain under#2I Remarks) FROM TO DESCRIPTION(col"r,hardness,soil/rock type grain s ze etc.)
0 it ft. Red Clay
4.Date Well(s)Completed: 11-1-23 Well ID# 6 ft• 13 ft- Brown Clay
5a.Well Location: 13 ft- 350 ft-
Granite
•
Northway Homes ft rt r' r_ ii i ;k`_
Facility/Owner Name Facility ID-9(if applicable) it ft.
10616 Old Camden Rd.Midland 28107 ft. ft. , FEB 0 5 2024
Physical Address,City,and Zip ft ft ;`1 , ^M u )
Mecklenburg 139-181-08 21.REMARKS . ' Dtty%tiBt.It, _' ,
County Parcel Identification No.(PIN) ',
Liner Installed at 75'to seal off iron seams
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 1
34.50.298 N 80.27.184 w
' ' 12-4-23
6.Is(are)the well(s)MPennanent or ITetnporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certl that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 5 Yes or al No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill oat drown 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: 350 (ft-) 24a. For All Wells: Submit tliis 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: 22 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servicet'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
`1Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply &injection 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: 70% HTH Amount: 12oz completion of well construction toj the county health department of the county "
where constructed. I
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016