GW1-2021-02472_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver `14,.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
416 ft. 485 fL
3002-A et, ft.
497
NC Well Contractor Certification Number ,15.OUTER'CASING,(for;inatti•casea'wells)OR LINER(ifsa'"licable 'n=
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 rL 67 ft 6118"' i"' 1 SDR21 PVC
e
�16:INNER'CASING OR TUBING t:otHeimal dosed-loo •:'>
2.Well Construction Permit#: 13481 FROM TO DIAMETER THICKNFSS MATERIAL
fL in.List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft.
3.Well Use(check well use): It. ft. rn.
."11:SCREEN r ,
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural OMunicipal/Public 0 ft. fa in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. FL
Industrial/Commercial Residential Water Supply(shared)
._ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ fL Bentonite Pour 01 501b Bags
Monitoring ORecovery M ft.
Injection Well:
fL ft.
Aquifer Recharge OGroundwater Remediation
19."�SANDIGRAYEli PAC&(if applicable)
-
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology 13 Subsidence Control ft. et
Geothermal(Closed Loop) OTracer 20:DRILLING`LOG attachaddidonaYslieets if necessa
FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks)
0 ft. 9 ft. Red Clay
4.Date Well(s)Completed: 5/11/2021 Well ED# 9 ft' 48 R' Brown Sandcla
5a.Well Location: 48 fL 500 ft' Grant e
Jada Warnock ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
106 Hannaford Place Gastonia 28052 ft. ft.
Physical Address.City.and Zip ft. ft. ;
Gaston 3522-98-46372i:REMARKS_,,.•'d -E. 1 �`,
County Parcel Identification No.(PIN)
Y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e..
(if well field,one lat/long is sufficient) 22.Certification: �t093rnfi@�
�ita.,tt,. Dy"u"��BOY;011
35.11.255 N 81.15.392 W __ _
� 5/21/2021
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s)was(were)constnu4ed in accordance
7.Is this a repair to an existing well: OYes or WNo with 15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
1f 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 ouster.
repair under#21 remarks section or on the back of this fonn.
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: 500 (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: 61 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 Iniection 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
k
13a.Yield(gpm) 45 Method of test: Air 24c.For Water Supply&Iniection 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: 300Z completion of well construction to the county health department of the county
where constructed. fI
Forst GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
i