GW1-2021-02492_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14:WATER ZONES "' ice,
FROM TO DESCRIPTION
Well Contractor Name
38 ft. 69 ft.
3002-A ft ft.
104
NC Well Contractor Certification Number J5 OUTER,CASING(for multi-easeit",*0 s)OR 1 1NER(if a'' [[cable)'
H,.
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company
0 ft' 33 ft' 6 1/8" in' SDR21 PVC
P Y Name ?`16::INNER EASING OR TUBING" eotherriral closed loo "''"`
2.Well Construction Permit#; 13371 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): et ft in
;17.SeREEN R ...-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fa fL in.
Industrial/Commercial OResidential Water Supply(shared) IS.GRO1J1 ,,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour 18 501b Bags
Monitoring ORecovery ft. ft.
Injection Well: iL
,_ Aquifer Recharge OGroundwater Remediation
'-kWSANI)IGRA-VE1;PACK(ifa' licatile,:.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage
Experimental Technology 13Subsidence Control ft. fa
Geothermal(Closed Loop) Tracer ;20."DRILLING'LOG.attach<addidonal's'lieeO'if necessai
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiltrock type,gmin size,etc.)
0 ft. 9 ft, Red Clay
4.Date Well(s)Completed: 4/21/2021 Well ID# 9 ft 26 ft' Brown`Dirt/Rock
5a.Well Location: 26 ft. 150 ft' Granite
Justin Padgett ft. et.
Facility/Owner Name Facility ID#(if applicable) ft• ft. . e
515 Amanda Faith Ln. Mt Holly 28120 Springs Creek II Lot#19 ft. fL b°�
Physical Address,City,and Zip ft
Gaston 21 REMARKS I
„fir 3t o�
County Parcel Identification No.(PIN) pro
t
D�Jt 'a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
35.17.580 N 81.30.533 W
^�. 5/18/2021
6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Weil Contractor Date
By signing this fonn, I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or 5allo with I SA 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 form.
23.Site diagram or additional well details:
S.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 (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 2@I00') construction to the following:
10.Static water level below top of casing: 25 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 Infection 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) 14 Method of test- Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit fone copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oZ completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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