GW1--04993_Well Construction - GW1_20240828

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
3002-A 160 rt. 234 ft.
257 rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 53 ft' 61/4 in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 10014471 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable wr!1 construction permits(i.e.LUC,County,Stare,Variance,etc.) ft. It. In.
3.Well Use(check well use): ft. ft. to
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATER(1I.
['Agricultural ()Municipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) 51Residential Water Supply(single) ft. ft. tn.
Dlndustrial/Commercial Residential Water Supply(shared) is.GROUT
('Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(15)50Ib Bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft-
DAquifer Recharge ()Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) —
['Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL YAWL A('FMENT METHOD
['Aquifer Test ChStoimwater Drainage
ft. ft.
Experimental Technology ()Subsidence Control ft. ft
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG_ (attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft. 17 ft- Red Clay
4.Date Well(s)Completed: 7-3 24 Well ID# 17 ff 25 ft. Brown Sandclav
5a.Well Location: 25 ft. 40 ft- Brown Rock
Logan&Emily Yeomans 40 ft- 300 it. Granite i ` ''-
.
ft. ft.Name Facility ID#(if applicable)
10711 Hadlow Ct. Charlotte 28277 ft. ft. A U G 2 8 2024
Physical Address,City,and Zip ft ft. ,
Mecklenburg 113-251-69 21.REMARKS C''!1'>i. ,_ 3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35.12.812 N 80.59.885
....; 0 7-23-23
6.Is(are)the well(s)�Permanent or ['Temporary Signature of Certified Well Contractor Date
By signing this form. 7 hereby certify that the weU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or gallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constructirm information and explain the nature of the copy of this record has been provided to the sir!!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: 300 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiplc welts list all depths if different(eranlple-34;200'and 24)100') construction to the following:
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 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) 12 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% HT Amount: 18oz 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