GW1-2021-02732_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t
Frankie L.Oliver
Well Contractor Name FROM TO DESCRIPTION
67 rL 191 ft.
3002-A ft. ft.
NC Well Contractor Certification Number
FSrOL TR CASING-(for'
Carolina Well Drilling FR mliltl-caved tvells)OR1ANER if-a`licabie).
OM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 fL 163 1" 6 1/8", r" 1 SDR21 PVC
, 16:3NNER CASINGOR TUBING. eothermal closed goo 7
2.Well Construction Permit#: 13393 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
'17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft, in.
Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 1g:GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ fL Bentonite Pour 23 501b Bags
Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
50."SAND/GRAVEL=PACK(if a' ikable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) OTracer -?A:')DRILLING LOG-att6ch`addid6nal sheets if necessar
FROM TO DESCRIPTION(color,hardness,soil/rock ly rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 15 ft, Red Clay
4.Date Well(s)Completed: 4/26/2021 Well ID# 15 ft' 50 ft. Brown`Dirt/Rock
5a.Well Location: 50 ft. 200 ft. Granite
Justin Padgett ft ft. e4.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
531 Amanda Faith Ln.Mt Holly 28120 Springs Creek II Lot#21 fL ft. r 021
Physical Address.City,and Zip ft. ft.
v
Gaston 3587-40-0673 �21:1tEMARKs
S,jr
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.18.003 N 81.30.510 �
5/18/2021
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor i Date
By signing this.fonn,/hereby certib•that the well(s)was(were)coustucted in accordance
7.Is this a repair to an existing well: OYes or 53No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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 fora. 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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells Cut all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 18 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring,use '+" 1617 Mail Service Ceriter,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
I
13a.Yield(gpm) 12 Method of test: Air 24c.For Water Supply &Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone 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