GW1-2022-08537_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DES
A - 4459 ft. ft.
ft. ft. �
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 rt. 1.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 rt. 15.0 ft. 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft. PORTIANDBENTONITE SLURRY
❑Monitoring ❑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 METHOD
El Aquifer Test ❑StormwaterDrainage 4.0 ri- 15.0 ft. 20-40 FINE SILICA SAND
❑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 I TO DESCRIPTION color,hardness,soiVmck type,grain size,etc.
0.0 ft. 15.0 ft. SILTY CLAY
4.Date Well(s)Completed: 04/19/22 well ID# LFG-33 ft. ft.
5a.Well Location: ft. ft.
PLEASANT RIDGE SCHOOL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1260 FLOYD LANE GASTONIA 28052 ft. ft.
Physical Address,City,and Zip
ft. ft.
GASTON 21.REMARKS
County Parcel Identification No.(PIN)
BENTONIfE SEAL-2.0-4.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***LANDFILL GAS PROBE***
(if well field,one lat/long is sufficient) 22.Certification:
350 15' 00.88" N 810 12' 20.73" W 4�
04/25/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)tivas(1vere)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell 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 wel con'§truction info
construction,only I 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 MAY 2 '20_'�
9.Total well depth below land surface: 15.0 (ft')
For multiple wells list all depths ifdiereni(example-3 200'and 2@100) Submit this GW-1 Within 30 days of well completion per the following:
Static water level below top of casing (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.
I10.St level is above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ivate11.Borehole diameter: 2.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HAND AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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