GW1--03609_Well Construction - GW1_20240613

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
114 ft. 136 ft_
3002-A
147 rt. et.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Well Drilling FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 112 ft. 61/4 in. SDR21 PVC
14202 16.INNER C:ISING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROMTO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. IL its
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MAT LW t 1.
DAgricultural DMunicipal/Public ft. rt. in.
El Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) tt. ft in.
Industrial/Commercial ['Residential Water Supply(shared) ls.('ROUT
(,Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20+ It. Bentonite Pour(101)50Ib Bags
°Monitoring °Recovery IL ft.
Injection Well: fL It.
BAquifer Recharge °Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStotntwater Drainage U. It.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.(DRILLING LOG(attach additional sheets if necessary)
FRO\t TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
°Geotherrnal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft' 14 ft Red Clay
4.Date Well(s)Completed: 4-1-24 Well ILA 14 fL 73 ft- White Sand
5a.Well Location: 73 fL 102 ft Brown Sand/Gravel
Justin Padgett 102 it 150 it Graniter r�3��V
Facility/Owner Name Facility ID#(if applicable)
ft. tt, V
525 Blacksnake Rd.Stanley 28164 ft. ft. ►�l
Physical Address,City,and Zip ft. ft J U Iv 1 S 2024
Gaston . 3579-86-4805 21.REMARKS 11AOrt t en arty ytftrlt U1
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:
35.22.16 N 81.50.50 W
Qle:l�/s 4-24-24
6.Is(are)the well(s)CaPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this,form,1 hereby certify that the weals)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Eallo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 We/i 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 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 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: 150 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welt list all depths ifdiffcrent(example-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (IL) 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) 30 Method of test: Air 24c.For Water Sunnly & 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: 12oz 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