GW1-2022-02896_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
7,
Frankie L.Oliver
FROM TO DESCRIPTION
Well Contractor Name 90 1" 151
3002-A 192
NC Well Contractor Certification Number 41'OUTEwCASINd v at ntilti-calleityiills) llcilible)�:
i i 'OR'LINER-ER(Irri
Carolina Well Drilling FROM I TO 1 DIAMETER MICKNESS MATERIAL
Company Name 0 1 87 rl1 6 1/8 1 SDR21 PVC
CASING OR,TURING(geothermal
2.Well Construction Permit#: 13398 FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) rL ft. In.
3.Well Use(check well use): rL ft. in.
Water Supply Well: FROM TO DIAMETER SLOTS17Y. THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. L in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) fL L In.
Industrial/Commercial [3Residential Water Supply(shared) '7
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT I
Non-Water Supply Well: 0 rL 20+ ft' Bentonite Pour(28)501b Bags
Monitoring pRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
,S,19.SAND/GRAVRC
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ostormwater Drainage ft. ft. I
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Traccr
'Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0rr' 53 rL Brown Sand/Rock
4.Date Well(s)Completed:2-9-2022 Well ID# 53 200 fl Granite
Sa.Well Location:
Justin Padgett ft. ft.
Facility/Owner Name Facility TD#(if applicable)
540 Amanda Faith Ln. Mt.Holly 28120 Springs Creek Lot#26
Physical Address.City.and Zip ft. ft.
Gaston 358741-2063
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification:
35.18.40 N 81.30.50 W , 2-18-2022
6.Is(are)the well(s)MPermanent or E)Temporary Signature of Certified ell Contractor Date
By signing this fonn, hereby certify that the ivell(s)it-as(were)Constructed in accordance
7.Is this a repair to an existing well: []Yes or QNo is-ith 15A NCAC 02C. 100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill nut known well construction infornialion and explain the nature of the copy of this record ha;been provided to the well owner.
repair tinder#21 remarks sections or on the back of this fonn. 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INS FRUCTIONS
9.Total well depth below land surface: 200 (ft-) 24a. For All Weill: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the lollowing:
10.Static water level below top of casing: 40 Division.if Water Resources,Information processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,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 (lowing:
(i.e.auger,rotary,cable,direct push,etc,) io
Division of Wa er Resources Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water SuoDIv&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: 120z completion of well construction to,the county health department of the county
I where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division o Water Resources Revised 2-22-2016