GW1--07936_Well Construction - GW1_20231208

I ;
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER'ZONES;. h.>T i ` `"
FROM TO DESCRIPTION
Well Contractor Name
141 ft 155 ft
3002-A
182 ft 205 ft 209 220,240,285,289
NC Well Contractor Certification Number „715.OUTER CASING(for ultt casedswells)OR LINER Of applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERL4L ,
Company Name 0 ft 108 ft 611/4` in' SDR21 PVC
•16-INNER•CASING OR TUBING Tgtiothernial closed=loop),
13972 "_;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc.) ft ft. I in.
3.Well Use(check well use): ft ft. 1 in.
17.SCREEN ,-;'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iv,i1Residential Water Supply(single) ft ft. ilL
Industrial/Commercial QIResidential Water Supply(shared) lii::GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ ft Bentonite Pour(83)50lb Bags
Monitoring DRecovery ft. ft.
Injection Well: ft. It.
Aquifer Recharge 0 Groundwater Remediation „
A9.rSANDIGRAVEL PA"C'K"cif applicable)l- i:',` -
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStotmwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.-I)RILLING LOG(attach additional sheets if necessary) ''''
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc.)
0 ft 6 ft Red Clay
4.Date Well(s)Completed: 11-8-23 Well ID# 6 it 19 ft Brown Clay
5a.Well Location: 19 ft 37 ft Brown Clay/Rock
Bryan Scott Wright 37 ft 100 ft Brown Sandclay
Facility/Owner Name Facility ID#(if applicable) 100 f 300 f Granite 3'^-• : ,—:q� ,7- rr—,,,
330 Morris Farm Rd.Stanley 28164
Physical Address,City,and Zip ft. ft. DEC V 8 2023
Gaston 3589-12-9695 21.REMARKS„ , . . '''- ";
Int:.r,r ,.n ' Y g(jest
County Parcel Identification No.(PIN) D`:1 Q f7 h c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.21.396 N 81.40.364 `1,
• 11-20-23
6.Is(are)the well(s)MPennanent or oTeanporary Signature of Certified Well Contractor Date
By signing this,form, 1 hereby cert(i5'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or a!jiNo • with 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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 site details or well
construction,only 1 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@l00') construction to the following:
1
10.Static water level below top of casing: 35 (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: 1
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servicet Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 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' Revised 2-22-2016