GW1-2022-08827_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Richard Mooney '.14:WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2980-A 20 fL 30 fL Sand,Fine,Corase
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Gcnble
Casacde Drilling FROM TO DIAMETER THICKNESS MATERIAL
fL fL �in.
Company Name
16.INNER CASING OR TUBING eothermel closed-loo ".
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Cmmty,State,Variance,etc.) 0 ft. fL 2 in Sch 40 PbC
3.Well Use(check well use): ft. It. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 30 ft- 2 in. 0.010 Sch 40 PrePacked
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 48.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Trimmle
nMonitoring ❑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
❑Aquifer Test ❑Stormwater Drainage 18 It- 30 IL #2 Trimmie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiumck type,grain size,etc.
ft. ft- SEE ATTACHED REPORT
4.Date Well(s)Completed: 8-2-22 Well ID# TW-15 ft. ft. * ;
Sa.Well Location: ft. ft. "" q
Gaston County Landfill ft. ft. V
Facility/Owner Name Facility ID#(if applicable)
ft ft. c"
1605 Old NC Hwy , Mt Holly NC 28120 ft. ft. ,,::'.0 uril:
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:
(if well field,one lat/long is sufficient) 22.Cert tion:
N 11 pr-Z~LZ_
6.Is(are)the well(s): ❑Permanent or [!]Temporary Signature of Certified Well Contractor Date
Bysigning thisform,I hereby certijy that the wells)was(were)conriructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 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: 30 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 n 00'and 2@100')
10.Static water level below top of casing: 20 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 611 (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 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(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
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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