GW1-2021-02499_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankle L.Oliver
FROM WATER ZONES . .
FROM TO DESCRIPTION
Well Contractor Name
165 ft' 176 et.
3002-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a` licable)
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL,
Company Name in
0 rt 63 fl' 61/8" ' SDR21 PVC
16,INNER CASING'OR'TUBING(geothermal closed•loo
2.Well Construction Permit#: 13375 FROM TO 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. fL in.
Water Supply Well: 47.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residentiai Water Supply(shared) iS:GROUT ,
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ ft. Bentonite Pour 38 501b Bags
Monitoring ORecovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a' licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. rL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additonal sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness mil/rock type,grain size,etc.)
0 ft' 15 ft- Red day
4.Date Well(s)Completed: 4/19/2021 Well ID# 15 ft' 54 ft' Brown'Dirt/ROck
5a.Well Location: 54 fY• 200 ft. Granite
Justin Padgett ft' ft'
e
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
528 Amanda Faith Ln. Mt Holly 28120 Springs Creek II Lot#29 ft. ft.
Physical Address.City,and Zip ft. ft. MAY 2 7 202
Gaston 3587-40-3536 21.REMARKS
County Parcel Identification No.(PIN)
^rl;;atien Pr^Cessing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.18.100 N 81.30.514 W
5/18/2021
6.Is(are)the weli(s)&Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this,fonn,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or 53No with 15A NCAC 02C.0100 or 15A 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 onwer.
repair tinder#21 remarks section or on the back of this forni. i
23.Site diagram or additional wen(details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page[o 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 list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 21 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 Infection 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) 4 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: 12oZ 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