GW1--03602_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.Vs ATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
78 ft. 86 ft.
3002-A
92 ft' ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased welts)OR LINER(if applicable)
Carolina Well Drilling FROM TO ULAMETER THICKNESS MATERIAL
Company Name 0 ft. 74 n' 61/4 1"' SDR21 PVC
16.INNER CASING OR TUBING(geotherm al closed-loop)
10014297
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County, etc.) ft. fL in.
nn n scare,Variance,
3.Well Use(check well use): it.. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ()Municipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) 5aResidential Water Supply(single) ft. ft. i».�
Industrial/Commercial DResidential Water Supply(shared) ls.('ROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:Monitoring
Injection Well:
0 f` 20+ ft. Bentonite Pour(45) 501b Bags
Recovery ft. ft.
ft. ft.
Aquifer Recharge Groundwater Remediation
I9.SAND/GRAVEL PACK(if applicable)
aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. It.
rj Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING I.OG(attach additional sheets if necessary)
FROM 10 DESCRIPTION'color,hardness,soil/rock type,grain size,eta)
()Geothermal(Heating/Cooling Return i fOther(explain under#21 Remarks)
0 f`' 16 fL Red Clay
4.Date Well(s)Completed: 4 4-24 Well ID# 16 I(. 43 I`' Red/Brown Clay
5a.Well Location: 43 ft 64 ft' Brown Sand/Gravel
Nicolae Hasegan 64 IL 150 ft. Granite 1--7
--
r._ii�ED
Facility/Owner Name Facility ID#(if applicable) ft ft \r.. �I(� ,
441 Creston Circle Charlotte 28214 f` ftc JUN 1 3 20?4
ft. ft.
Physical Address,City,and Zip
Mecklenburg 053-022-23 21.REMARKS ,r, ,- " ' ,,, -"`
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.17.46 N 80.59.00 W
4-24-24
6.Is(are)the well(s)RIPermanent or OTcmporary Si of ertified Well Contractor Date
By signing this form, I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or Eallo with ISA 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 o(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: 150 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(atomic-3 00'and 2Q100') construction to the following:
10.Static water level below top of casing: 9 (ft.) Division of Water Resources,Information Processing Unit,
>fwater 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.c.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) 100 Method of test: Air 24c.For Water Sumuly &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: 1 2oz 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