GW1-2021-02490_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Frankie L.Oliver 14 wARzoN�s=
FROM TO DESCRIPTION
Well Contractor Name t
3002-A 54,84 ft. 87.95 fL
102 n' 156 ft
NC Well Contractor Certification Number
$'i-1tTERrGA51 Gi fot'iniild cased t"filis.OR'Is1NER'IP-o liceble�V:,` ^':�$�::
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 rt' 51 ft' 61/8: I"' SDR21 PVC
Company Name
:..15r: ER'CASING.OIt,TUBING eotherinal`closed-loo
2.Well Construction Permit#: 13370 FROM I TO DIAMETER THICKNESS - MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ri. ft. in.
3,Well Use(check well use): i't. fL In.
=17>-SCREEN , ,r' c. ? :` r
Water Supply Well: FROM I TO I DIAMETER SLOTSIZE THICKNESS MATERIALS
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) n n, In.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO I MATERIAL E.MPLACEMENT METHOD SAMOUNT
^
Non-Water Supply Well: 0 n' 20+ n' Bentonite Pour 41 501b Bags
Monitoring DRecovery ft rL
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
%A SAND/GRAVRL.,RkC ire' lic>ab11 ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer r 2(1'DRILLIIVG.LOG,iifta'ch nddltlonei Ahaets U,riecessar '>:F,
FROM TO - DESCRIPTION(color,hardness sall/roek l '^in size etc.)
Geothermal(Hearin /Cootin Return) (explain under#21 Remarks) 0 D' 6 r` Red Clay
4.Date Well(s)Completed: 4-9-2021 Well ID#_ 6 fL 27 rL Brown Dirt/Rock
Sa.Well Location: 27 n' 175 fL Granite
Justin Padgett
Facility/Owner Name Facility ID#(if applicable)
508 Amanda Faith Ln.Mt.Holly 28120 Springs Creek II Lot#34 rL ft. '
Physical Address,City.and Zip ft. ft.
Gaston PID#12207321;RIDiARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
35.17.570 N 81.30.521 w
r.. 5-3-2021
6.Is(are)the well(s) Permanent or 13Temporary Sig'"MVf of Certified Well Contractor Date
By signing this form, I hereby cernify that the nrll(s)was(were)consnrnted in accordance
7.Is this a repair to an existing well: E]Yes or JoNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandmds and that a
If this is a repair,fill out knoum well construction htformarion 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-I 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: 175 (fW 24a. For All Wells: Submit this Iferm within 30 days of completion of well
For mulliple wells list all depths if different(example-3Q200'and 2@1001 constriction to the following:
10.Static water level below top of casing: 25 (fL) 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 fonn within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
DivWou 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 Suouly&Infection 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: 12o2 completion of well construction to'the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016