GW1-2021-01481_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
165 ft' 275 rL
3002-A
ft. ft.
NC Well Contractor Certification Number .15.'OUTER CASiNG`(foranuW-cased wells O LINER(if a' licable)'
Carolina Well Drilling FROM TO DIAMETER R THICKNESS MATERIAL
Company Name 0 ft. 47 eL 6 1/8"i '"' SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop),.
2.Well Construction Permit#: 19-250 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): fL ft. in.
1Z'SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT,
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ ft' Bentonite Pour 14 501b Bags
Monitoring ORecovery fL ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
.19rSAND/GRAVEL PACK(if applicable)'
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT MF,THOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Heatin(Heating/Cooling Return Other(explain under#21 Remarks ft ►`sheets if,hardness,
Geothermal Closed Loop) Tracer 20.DRILLING LOG attach additions
FROM TO DESCRIPTION(color,hardness,soiVrock t e, rain size etc.)
( g g ) ( ) 0 6 Red day
4.Date Well(s)Completed: 3-26-2021 Well ID# 6 ft' 22 fL Brown,Dirt/Rock
5a.Well Location: 22 200 fL Granite
William Matthews et et.
Facility/Owner Name Facility ID#(if applicable) ft. fL
3700 Deer Hollow Dr.Gold Hill 28071 Lot#2(Well on Lot#1) fL ft. 21
Physical Address.City,and Zip ft. ft.
CabarruS 21.REMARKS -sr 0
County Parcel Identification No.(PIN) nIII,
WR Sad t0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Vv
(if well field,one lat/long is sufficient) 22.Certification:
35.28.073 N 80.19.244 W
4-12-2021
6.Is(are)the well(s)&Permanent or Temporary Si re of Certified Well Contractor Date
By signing this form, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or WNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knomi well construction information and explain the nature of the copy of this record has been provided to the well ouvner.
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 l 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 multiple wells list all depths if different(example-3@100'and 1@1001 construction to the following:
10.Static water level below top of casing: 24 Division of Water Resources,Information Processing Unit,
I(water level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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) 50 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 180Z 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