GW1-2021-02494_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver
514:,WAT3''iR�
FROM TO DESCRIPTION
Well Contractor Name
89 it. 103 fL
3002-A 172
NC Well Contractor Certification Number 15,;Oi1Ti R CA5 Gi trio altl cased;" Is: R tit1V6R' "lieable
Carolina Well Drilling FROM TO DIAMFTER TInCKNESS MATERIAL f
Company Name 0 ft- 68 f' 6 1/8 In' SDR21 PVC
16:3N1VIsRtCvASI[dGOTt= UB1NG;`2''liertpaleloseddod ,'"'.,' r `<
2.Well Construction Permit#• 13373 FROM TO DIAMETER TIRCKNFSS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• fL in.
Water Supply Well: FROM I To I DIAMETER ISLOTSI7.E THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. In.
Geothermal(HeatingiCooling Supply) QResidential Water Supply(single) n ft. In
IndustriaUCommercial 13Residential Water Supply(shared) `,r".18•GItb11T ,yn r •s• ,.h.ai -.`rosy77777777
711trigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 1 20+ ft* Bentonite Pour 13 501b Bags
Monitoring Recovery ft. rL
Injection Well:
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. n•
Geothermal(Closed Loop) Tracer ':2or1)1t11 ii1NGl 1DG ettacli;Additldifht'iiheetl Ir;iiecessarv) 7
FROM I TO TION(colorcolor,hardness,sofUroek t ._. In slae,etc.
Geothermal(Heatin !Cooling Return) DESCRIPTION
Other(explain under#21 Remarks) 0 tt 10 fQ Red
ay
4.Date Well(s)Completed: 4-16-2021 Well lam# 10 fL 15 ft- Wet Red Dirt
Sa.Well Location: 15 ft 56 n irt/ROok
Justin Padgett 56 fL 200 fL Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
524 Amanda Faith Ln.Mt. Holly 28120 Springs Creek II Lot#30 f< f4 rin
t?•
ft. ft. `®
Physical Address.City.and Zip
Gaston 3587-4.0-3461
County Parcel Identification No.(PIN)
A; r1 n,aSSlf`i. UtZ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: \NR sbdon
35.17,589 i N 81.30.492 W 5-3-2021
6.Ware)the wells) Permanent or 13Temporary Signature of Certified Well Contractor ', Date
By signing this fort, I hereby certfp that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 53No whit 15A NCAC 02C.0100 or 15A NCAG 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of the copy of this record has been provided to the well onater.
repair under#21 remarks section or on the back of this fort. 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-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: 200 (fL) 24s. Ear All Wells: Submit this form within 30 days of completion of well
For nathiple t,,ells list all depths if&fjerent(example.3®200'and 2@100) construction to the following:
10.Static water level below top of casing: 25 (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 (inJ 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) 10 Method of test: Air 24c.For Water Supply&Infection 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: 12o2 completion of well construction to the county health department of the county
where,constructed. i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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