GW1-2021-02684_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver �aa:WATER7ANFS a
FROM TO DESCRIPTION
Well Contractor Name
83 n• 121 r`• j
3002-A 137 a. ft.
NC Well Contractor Cenification Number .t SeOVT-FRCASING oritiultl-cesed'tvclls OR'I1NER IFe"Ileabt8: r
Carolina Well Drilling FROM TO DGMETER THICKNESS MATERIAL.
0 rL 30 fa 10 ,In, SDR21 PVC
Company Name ,
.,d4i INNER CASING'iSRrTUBiNG i!atlieFmel closed=toa
2.Well Construction Permit#: 13431 FROM TO DIAMETER I THICKNESS I MATERIAL.
List all applicable Krell construction permits(i.e.UIC,Counry,State,Variance,etc.) 0 ft. 53 ft- 6 1/8 In- SDR21 PVC
3.Well Use(check well use): n• n• In.
Water Supply Well: FROM r0 I DIAMM.R SLOTSIZE THICKNESS MATERIAI.
Agricultwal [3Municipal/Public 0 ft. it. I In.
Geothermal(Heating/Cooling Supply) 631kesidential Water Supply(single) ft. ft,
Industrial/Commercial Residential Water Supply(shared) 18.GRbU f Irti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n. 20+ n• Bentonite Pour 9 501b Bags 10"
Monitoring DRecovery 0 rL 20+ fL Bentonite Pour 10 501b Bags 6 1/8"
Injection Well: n• n
Aquifer Recharge 13Groundwater Remediation
:'19 SA:i+ID'IGRA'p1;t•PAGK Ira' 116gti`le ..<< •''
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL. EMPI,ACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft fi.
Experimental Technology 13Subsidence Control n fL
Geothermal(Closed Loop) Tracer f 20€DRILLING'J:OG;attach addltlona6itBeetsdf.ne'cessnr s;
77
Geothermal(Heatin Coolin Return) nOther(explain under#21 Remarks FROM TO DESCRIPTION color,hardntss soil/rock t rain size etc.
0 f`. 14 fL Red/Brown Clay
4.Date Well(s)Completed: 4-7-2021 Well ID# 14 r`' 30 n. Bro n and/Gravel/Rock
Sa.Well Location:
30 ft. 42 n. Brown Rock e--
Brandon Moore 42 ft, 200 fL Granite ynyp�/
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4910 Bud Wilson Rd.Gastonia 28056 f`. n. f' 851n Ull"
�� ygr•.tton
Physical Address,City,and Zip
Gaston 3552-69-9221
�92i,Rb7M,ARKS�=V' .�
County
Parcel Identification No.(PIN) * 0 10" casing-and grouted to seal off sand/
gravel seam
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.90.422 N 81.90.902 W _"� r 5-3-2021
ir_
6.Is(are)the well(s)MPermanent or Temporary
Signature of Ce�ni'fied Well Contractor Date
By signing this form, I hereby cert(fy that the well(s)was(were)consinicted in accordance
7.Is this a repair to an existing well: [3Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knout well construction information and explain the nature of the copy of this record has been provided to the well otmer.
repair under#21 remarks seclion 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-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 00 24a, fgr All Wells: Submit this farm within 30 days of completion of well
For nndtiple wells list all depdrs if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 12 (fL) Division of Water Resources,Information Processing Unit,
If tenter 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) 26 Method of test: Air 24c.koor 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: 12oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I