GW1--04992_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD I GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
81 ft- 112 ft.
3002-A
145 rt. rt.
NC Well Contractor Certificatitm Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER 1IOCKNF:SS \11TFH1AI.
Company Name 0 ft. 67 rt' 61/4 `n' SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop1
10014603
Flt
2.Well Construction Permit# ll\t TO DI 1\IF:TEH THICKNESS >I\"1'F.RI:1I.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. ft. in.
3.Well Use(check well use): f`' ft. in.
17.SCREEN
Water Supply Well: Fltll\I TO DI IMETER SLOT SIZE THICKNESS \LATERI1L
Agricultural ElMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft ft. tn.
Industrial/Commercial D Residential Water Supply(shared) Is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD a AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft. Bentonite Pour(26) 501b Bags
Monitoring Recovery ! rt_ ft.
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EiSalinity Barrier FROM TO M 1TERLIL EMPLACEMENT METHOD
�Stormwater Drainage ft. ft.
Aquifer Test _
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION Icolur.hardness,soil/rock typo,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#2I Remarks)
0 rt 6 ft. Red Clay
4.Date Well(s)Completed: 7-9-24 Well ID4 6 It. 35 f` Brown Sand clay
5a.Well Location: 35 n- 55 Pt' Brown Sand/Gravel
Russell&Mitchell Yeomans 55 ft. 250 f`' Granite
Facility/Owner Name Facility ID#(if applicable) It ft- ,
10741 Hadlow Ct. Charlotte 28277 ft. fc
Physical Address,City,and Zip rt. ft �,I I 9. 1911.
Mecklenburg 113-251-70 21.REMARKS
County Parcel Identification No.(PIN) D/:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.12.833 N 80.59.901
7-23-23
6.Is(are)the wel(s)10Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the xeU(s) was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or IZNo 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 of this,forns
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 (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For nutltiplc wells list all depths if different(eranyzle-3(d 200'and 2Q1001 construction to the following:
10.Static water level below top of casing: 21 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"i-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inflection 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) 4 Method of test: Air 24c.For Water Sunnly&inlectlon 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: 16oz 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