GW1-2022-02893_Well Construction - GW1_20220228

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14:'WATER<wN
FROM TO DESCRIPTION
Well Contractor Name
92,96 n• 132
3002-A n'
148 ft' 162 fL 183,269.
NC Well Contractor Certification Number ,4S:'OUTER CASING 0f Inuld-eased•i 0W It LINER If,'a Itcable ;
Carolina Well Drilling FROM TO DIAMETER THICKNESS I MATERIAL
Company Name 0 n. 87 ft- 61/8 I"' SDR21 PVC
16 INNER'CASIN 'OR TUBING_ "ebtWrin,2I closed-loo
2.Well Construction Permit#: 13395 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): n. ft. in.
Water Supply Well: 17I:SCREEN
ppy FROM TO DIAMETER SLOTSIZF: THICKNESS MATERIAI.
Agricultural 13Municipal/Public f4 In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) A. L in,
Industrial/Commercial [3Residential Water Supply(shared) AS:GROUT,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rL 20 ft' Bentonite Pour 33 501b Bags
Monitoring . Recovery ft. ft.
Injection Well: ft fL
Aquifer Recharge Groundwater Remediation
rf19iSA1HD/GRAM"s 'kACK 7ta` IICAtile "�'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft'
Experimental Technology Subsidence Control ft. n.
Geothermal(Closed Loop) Tracer :20:DRILLING10 ,attach additionA14MilslGriecessa'
FROM TO DESCRIPTION color,hardness soll/mckt rain size etc.
Geothermal(Hearin /Coolin Return) Other ex lain under#21 Remarks)
0 ft• 2 fL Red Clay
4.Date Well(s)Completed: 1-11-2022 Well ID# 2 n' 80 ft' Brown$and Gravel
So.Well Location: 80 rt. 30 tL Granite
Justin Padgett n. n.
Facility/Owner Name Facility ID#(if applicable) ft. ft'
539 Amanda Faith Ln. Mt. Holly 28120 Springs Creek Lot#23 fL n
n.Physical Address.City,and Zip ft.
on
Gaston 3587-40-0926 :,2l.REh1ARKS;•.r
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.18.40 N 81.30.52 W 2-18-2022
6.Islam)the well(s)opermanent or Temporary 11gazure of Certified Well Contractor Date
By signing this fon n,I hereby certify that the well(s)has(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or oNo 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 it formation and explain the nature of the copy of this record hi s been provided to the Nell ohmer.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction detail;. You may also attach additional pages if necessary.
drilled: SUBMITTAL IN iTRUCTIONS
9.Total well depth below land surface: 300 (ft-) 24s. For All : Submit this form within 30 days of completion of well
Far mulliple wells lisl all depths if different(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: 34 (ft.) Divislor of Water Resources,Information Processing Unit,
If water level is above casing,use'•+- 161 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For In ectiori Wells: In addition to sending the form to the address in 24a
Air Rotarysubmitm above,also one copy of this for 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 Witter Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163 5 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Air 24c.For Water u 1 tf nWells: In addition to sending the form to
the address(es) a ove, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 180Z completion of well construction to the county health department of the county
where construct
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016
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