GW1-2022-02894_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD(GW-1) For Internal UseOnly:
1.Well Contractor Information:
Frankie L.Oliver
FROM TO DESCRIPTION
Well Contractor Name
70 7t 152 n
3002-A 223 rt- 256 f
NC Well Contractor Certification Number 115.'t7UTERCAStN fiir:roultl-eastdlig01 :OR LINER,tfa` licable , ;
Carolina Well Drilling FROM I TO I DIAMETER THICKNESS IMATERIAL
Company Name 0 "- 68 a 61/8 " SDR21 PVC
r1&INNER?CASING RTUBING''eothermal'cloted lob
2.Well Construction Permit#: 13399 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. h. In.
3.Well Use(check well use):
Water Supply Well:
ppy FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPubtic fY is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. In.
Industrial/Commercial Residential Water Supply(shared) 18 GRGUT, t..-.
Irrigation FROM TO MATERIAL~ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ rL Bentonite Pour 32 501b Ba s
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
,49.'SANWGRAVEI A'CK tta'"Iltytlile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Technology Subsidence Control It. n.
Geothermal(Closed Loop) OTracer 20 I)RIILL7NGr°GIG attach"iddldbnil''slt'eets•if rieeessa ?;
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solttrock t Amin sloe etc.
0 r- 2 fL Red Clay
4.Date Well(s)Completed: 1-13-2022 Well M# 2 rt' 31 fL Brown Clay
Sa.Well Location: 31 ft. 55 fL
Brown,Sand/Gravel
Justin Padgett 55 n. 300 fL Granite
Facility/Owner Name Facility tD#(if applicable) ft. H
536 Amanda Faith Ln.Mt. Holly 28120 Springs Creek Lot#27 rl. ft.
Physical Address,City,and Zip ft. ft'
Gaston 3587 AO-2586 '21�1WMARKS­-1,'5t',',.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: P
(if well field,one lat/long is sufficient) 22.Certification:
35.18.30 N 81.30.50 W
2-18-2022
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified V ell Contractor Date
By signing this form, 1 Piereby certify that the rte/l(s)was(were)constnte•ted in ace»rdmrce
7.Is this a repair to an existing well: 13Yes or QNo with 15A NCAC 02C.0 100 or 15A NCAC 02C.0200 Well Construction Smndards and that a
/f this is a repair,fill our known Hell 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 forth.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INS RUCTIONS
9.Total well depth below land surface: 300 (ft-) 24a. For All Weilsi` Submit this form within 30 days of completion of well
For multiple Hells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 35 (ft.) Divtslon o Water Resources,Information Processing Unit,
If water level is above casing,ttse"+" 1617 T fall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection ells: 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 fo lowing:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 DWI Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Air 24c.For Water Su ply&Iniectiori ells: lit addition to sending the form to
the address(es) above, also submit tone copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 18oz 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 "ter Resources Revised 2-22-2016