GW1--04425_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver -,14.,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
237 ft. 274 It.
3002-A ft. ft.
NC Well Contractor Certification Number iS.OUTER CASING(for multi-casedlwells)OR LINER(if ap licable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft* 61/4 in. SDR21 PVC
Company Name
'16.INNER CASING OR TUBING(geothermal closed-loop) - ,
13740
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) - ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN:'°
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural IN Municipal/Public ft, ft. in.
Geothemral(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft, in.
Industrial/Commercial OResidential Water Supply(shared)
Di.GROUT I -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft" Bentonite Pour(16)501b Bags
Monitoring ORecovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEI`PACK(if applicable)'
Aquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) ri Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft 10 ft' Red Clay
4.Date Well(s)Completed: 6-3-23 Well ID# 10 ft' 60 ft' Brown Sandclay
5a.Well Location: 60 _ ft' 300 ft.
Granite
Justin Padgett ft. ft' r d-, .
Facility/Owner Name Facility ID#(if applicable) ft. ft. ` �' -- �' s`.. �r
208 Springs Creek Dr.Mt.Holly 28120 ft. ft. JUL- ) 0 2023
Physical Address,City,and Zip ft. ft.
Gaston 3587-40-7663 2L REMARKS- ' .. , •it:;u,r , . rl r„'.
County Parcel Identification No.(PIN) __
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.30.046 N 81.06.539 W
7-3-23
6.Is(are)the well(s)MPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: III Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our brown well construction information and explain the nature tithe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
23.Site diagram or additional well details:
S.For Geoprabe/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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft) 24a. For All Wells: 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 following:
10.Static water level below top of casing: 24 (ft.) Division of 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 Injection 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 following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 14 Method of test: Air 24c.For Water Supply&Injection 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: 18Oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
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