GW1-2021-02474_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver >,14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 81 ft- 377 eL
3002-A
379 ft' 383 fL
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)TO 1iINER if a""licable
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL,
0 eL 36 fL 6 1/8". ' SDR21 PVC
Company Name
16:INNER CASING OR TUBING'( eottiermal closed-loop)_
2.Well Construction Permit#: 13405 FROM TO DIAMETER TFICKNESS MATERIAL.
Cut all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 47.SCREEN
PP Y FROM TO I DIAMFTER ISLOTSIZE I THICKNESS MATERIAL.
Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT,
Irti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ et. Bentonite Pour 16 501b Bags
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
_)Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer '20.,DRILLING LOG attach additional sheets if necessary),
Geothermal(Heating/CoolingReturn) rl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiVroek type, in sill,etc.)
0 ft. 7 ft' Orange Sandcla
4.Date Well(s)Completed: 5/15/2021 well ID# 7 et' 13 f6 Orancieffirown Clay
5a.Well Location: 13 et' 400 eL Granite
Total Comfort Homes
Facility/Owner Name Facility ID#(if applicable) fI- ft. t
2911 Forbes Rd.Gastonia 28056 eL n
Physical Address,City,and Zip ft. ft. 021
Gaston 3543637286 21.'REMARK5
Count Parcel Identification No.(PIN) f^r1,n3t'tOrl Pro, Sing Unit
y p1"Vi 5scr.o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35.11.442 N 81.11.800 W
5/21/2021
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this.fonn, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 5allo 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 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 fornh.
23.Site diagram or additional welCdetails:
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 I GW-I 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: 400 (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@200'and 1@100') construction to the following:
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10.Static water level below top of casing: 69 (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 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
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13a.Yield(gpm) 60 Method of test- Air 24c.For Water Supply&Iniection 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: 24o2 completion of well construction to`the county health department of the county
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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