GW1-2022-02895_Well Construction - GW1_20220228

i
WELL CONSTRUCTION RECORD (GW-1) For Internal UseOnly:
1.Well Contractor Information:
Frankie L.Oliver �ia: Am�R2DN s
Well Contractor Name FROM TO DESCRIPTION
3002-A 91,94 n• 110 n'
145 rt' 150 fL
NC Well Contractor Certification Number
sa5:,9UT1£R�GA`SXN 'tU2,' iltl--casedaw�llsORt[;XNER-IP:a"llcable -�
Carolina Well Drilling FROM TO I DIAMETER THICKNESS I MATERIAL
Company Name 0 n' 76 'L 161/8 i"- SDR21 PVC
13394 ;16:INNER',CASING OWTUBING e6therinal clused406
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,County,Slate,Variance,etc.) ft. fL In.
3.Well Use(check well Ilse): It. tt, lo.
Wafer Supply Well: FROM I TO DIAMETER SLOTSI7.F. THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. fL In
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared) 1g;GRb_UT
_ -Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lGeothermal
on-Water Supply Well: 0 20+ Bentonite Pour 28 501b Ba s
Monitoring Recovery It. ft.
jection Welt: ft. n.
Aquifer Recharge Groundwater RemediationYEXri' ACK tra 'li¢able Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL FMPLACEMF.NT METHOD
Aquifer Test [3Stormwater Drainage ft. n•
Experimental Technology Subsidence Control R. R.
Geothermal(Closed loop) AI
Tracer �10i,DR1LLINGD. tattochaddidonalsheett4f, , t rain sin etc.)(Heating/Conlin Return) Other(explain under#21 Remarks) FROM TO DFSCRIPTION(color,hardness soli/r=
0 n' 56 n Red Clay/Dirt
4.Date Well(s)Completed: 1-31-2022 Well ID# 56 n' 200 n Granite
5a.Well Location: n n
Justin Padgett ft. ft.
Facility/Owner Name Facility fD#(if applicable) n n'
535 Amanda Faith Ln.Mt. Holly 28120 Springs Creek Lot#22 rL ft.
ILL
Physical Address,City.and Zip ft. fL
Gaston 3587-40-0759
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:
35.18.40 N 81.30.51 W
2-18-2022
6.Ware)the well(s) Permanent or OTemporary erti red V fell Contractor Date
By signing this jonn, I hereby certify that the uwll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 51No u ith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction b forniation and explain the nature of the copy of this record has been provided to the well ouster.
repair under#21 remarks section or on the back of this jonn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the balk of this page to provide additional well site details or well
construction,only I 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 (ft-) 24a. For All Wells, Submit this form within 30 days of completion of well
For multiple wells list all depilts if different(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division o Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 T 4all 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 f Ilowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Watt Resources,Underground Ir lection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water So DIV& I ti t ells: In addition to sending the form to
the address(es) abo e, also submit'tone copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12o2 completion of welt onstruction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Maier Resources ! Revised 2-22-2016