GW1--03601_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
60,75 ft. 80,148ft.
3002-A 162 ft' 175 ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 54 ft" 6 1/4 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
10014294 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. tn.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) g, ft in.
Industrial/Commercial DResidential Water Supply(shared) is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft Bentonite Pour(51)50Ib Bags
Monitoring ()Recovery ft. ft.
Injection Well:
rt. ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStoimwater Drainage it. it.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION icolor,hardness,soil/ruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 6 ft.
Red Clay
4.Date Well(s)Completed: 4-10-24 Well ID# 6 it' 45 it' Grey Sandclay
5a.Well Location: 45 ft- 200 ft Granite
Thomas Hamer ft. It. %` L i�. /E
Facility/Owner Name Facility ID#(if applicable) it it �/
5042 Sentinel Post Rd. Charlotte 28226 et. ft. JUN 1 A 2024
Physical Address,City,and Zip f[. ft. lrJori,;,(;£n 1.ro.. g U.S
Mecklenburg 211-175-24 � -
County Parcel Identification No.(PIN) .
Sb.Latitude and longitude in degreeshninutes/seconds or dedmal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.10.688 N 80.81.405 W —
r 4-24-24
6.Is(are)the well(s)�Perrnanent or QTeutporary Signature of Certified Well Contractor Date
By signing this form, 7 hereby cenify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: ®Yes or Ilallo wit/,1SA 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 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 (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(a 200'and 2(41100') construction to the following:
10.Static water level below top of casing: 4 (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) 26 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 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