GW1-2022-08539_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14�WATERZONEs: �.
Well Contractor Name FROM TO DESCRIPTION
A - 4459 ft. ft.
ft. ft. ,
NC Well Contractor Certification Number I5 OUTER CASING'formuh-cased.wells`ORINKfa icable
GEOLOGIC EXPLORATION FROM D MATERIAL
ft. ft. in
Company Name
16.-INNER CASING OR-TUBING eothermaLclosed-Ioo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESSMATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 5.0 ft- 1.0 " SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: T`17:SCREEN nr
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 15.0 rt. 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,
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MEPHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft• PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation
19.:SAND/GRAVEL PACK if appiksiblef,
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMEPHOD
El Aquifer Test ❑StormwaterDrainage 4.0 ft- 15.0 ft• 20-40 FINE SILICA SAND
El Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING,LOG attach"addi8orial'sheets if necessary)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock a rain size,etc.
0.0 ft.
15.0 ft. SILTY CLAY
4.Date Well(s)Completed: 04/19/22 well ID# LFG-34 ft. ft.
Sa.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 2L;REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-2.0-4.0 FEET
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***LANDFILL GAS PROBE***
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 00.88" N 810 12' 20.73" W �
04/25/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)spas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 el dilstruction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additiona pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS t�
9.Total well depth below land surface: 15.0 MAY 2 7 202
For multiple wells list all depths ifelifferent(example-3@200'and 2@100� (ft*) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"
11.Borehole diameter: 2.25 (in,) 24b.For Injection Wells: Copy to DWI,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