GW1-2021-02497_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES;.
FROM TO DESCRIPTION
Well Contractor Name
186 ft' 191 k.
3002-A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING(for multbcased wells)OR LINER if a' lit able)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 53 rL 61/8" II"' SDR21 PVC
16.INNER CASING OR TUBING eothertnaI ctdsed-loop)
2.Well Construction Permit#: 13374 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) fL ft. I in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAI.
Agricultural 13Municipal/Public 0 ft. ft. in. I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) et ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18:'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rL 20+ ft' Bentonite Pour 20 501b Bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
�=19.SAND/GRAVEL PACK.if a llcahle' '
Aquifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG fattich additional sheets if necessar
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUmck type,grain size,etc.)
0 ft' 6 rL Red Clay
4.Date Well(s)Completed: 4/22/2021 Well ID# 6 ft' 45 rL Brown%Oran a Dirt
5a.Well Location: 45 ft' 200 1" Granite
Justin Padgett fc rt'
Facility/Owner Name Facility TD#(if applicable) ft. ft.
525 Amanda Faith Ln. Mt Holly 28120 Springs Creek II Lot#20 fL ft. td
Physical Address.City,and Zip M ft.
Gaston 3587-40-1407 21.:REMARres =
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �PI;J11�,3 tt Yi t `
(if well field,one lat/long is sufficient) 22.Certification:
35.18.000 N 81.30.845 W
�� 5/18/2021
6.Is(are)the well(s)&Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)teas(were)consbmeted in accordance
7.Is this a repair to an existing well: []Yes or RNo with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information aid explain the nature of the copy of this record has been provided to the well onvter.
repair tender#21 remarks section or on the back of this font.
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 tIo 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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Cut all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 17 (ft.) Division of Water Resources,Information Processing Unit,
7f water level is above caring,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
13a.Yield(gpm) 35 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: 120Z completion of well construction to;the county health department of the county
where constructed.
`i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016