GW1-2022-08117_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Richard Mooney 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
40 rt 50 ft Sand,Fine,Corase
2980-A
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for oa114ased wells OR LINER if a lies hle,
Casacde Drilling FROM To DIAMETER THICKNESS M" iii 11.
ft ft in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-ioo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft 40 ft 2 t"' I Sch 40 PVC
3.Well Use(check well use): ft I ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40 ft- 50 ft' 2 i"' 0.010 Sch 40 PrePacked
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft a• _ Trimmie
IlMonitoring ❑Recovery ft ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT NF"FHOD
❑Aquifer Test ❑Stormwater Drainage 38 ft 50 ft #2 Trimmie
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardne soil/mck type,Krain size,etc.
ft fL SEE ATTACHED REPORT
4.Date Well(s)Completed: 8-2-22 Well ID# TW-16 ft ft
5a.Well Location: ft. ft.
Gaston County Landfill ft ft t,_
Facility/Owner Name Facility ID#(ifapplicable) ft ft -
1605 Old NC Hwy , Mt Holly NC 28120 ft ft
Physical Address,City,and Zip ft ft
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
Pre-Packed screens,abandon after water sample
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22,C tifreation:
N W e'_2 r.
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Corlfcactor Date
By signing this form,I hereby certify that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under=21 remarks.section 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50 (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf different(example-3 a 00'and 2@100')
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use" "
11.Borehole diameter: Err (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Sonic
24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments eat department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralei ,NC 27699-161 I
13m.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

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