GW1-2022-02897_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD (GW-1) For Internal UseOnly:
1.Well Contractor Information:
Frankie L.Oliver 74�VA1ERtiONN sd��.
FROM TO DESCRIPTION
Well Contractor Name
91 fi' 117 1-
3002-A a.
192
NC Well Contractor Certification Number 45:i0UTER'CASIN for multi-tased.ivells;OR LINER tPs"""Nrable
Carolina Well Drilling FROM TO DIAMETER THICKNFSS MATERIAL
Company Name 0 rL 53 ft' 61/8 In. SDR21 PVC
13396 146ANNERCASIN OWTUDING` eotltertlivtdos l loo
2,Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) H. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well
PPY : FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. IL in.
Geothermal(Heating/Cooling Supply) BaResidential Water Supply(single) ft in.
Industrial/Commercial Residential Water Supply(shared) A$.MROUT
Irrigation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft. Bentonite Pour 29 501b Bags
Monitoring EIRecovery fl. rL
Injection Well: fY. ft.
Aquifer Recharge 13Groundwater Remediation
919::SAND/GRA'iYh`h ACRi 1fa licaUf ... '
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. rL
Experimental Technology Subsidence Control n• R•
Geothermal(Closed Loop) 13Tracer ',,62Q4',DR1LXlNG1_0`G attachaddiaonaliiheels3iftiieeessar
Geothermal(Hearin Conlin Return) Other(explain under fY21 Remarks) FROM TO DESCRIPTION color,hardness soll/rock t gain size etc.'
0 t1' 13 f' Fill Clay
4.Date Well(s)Completed: 2-15-2022 Well ID# 13 ft' 45 rL Brown Sand Rock
So.Well Location: 45 ft' 200 fa Granite
Justin Padgett ft. IL
Facility/Owner Name Facility ID#(if applicable) n' ft.
543 Amanda Faith Ln.Mt. Holly 28120 Springs Creek Lot#24 ft. ft.
Physical Address.City,and Zip ft. ft.
Gaston 3587-31-9193L REMARxs°'.,�
UnA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.18.60 N 81.30.52 W
2-18-2022
6,Is(are)the well(s)JaPermanent or OTemporary Signature of Certified N tell Contractor Date
k,signing tins form, 1 hereby c•errify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or WNo with 15A NCAC 02C.t 100 or 15A NCAC 02C-0200 Well Construciian Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of file cop),of this record has 5een provided to the well owner.
repair tinder#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 ba k of this page to provide additional well site details or well
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
NS
drilled: SUBMITTAL I RUCTI S
9.Total well depth below land surface: 200 (ft-) 24a. For All 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 f Ilowing:
10.Static water level below top of casing: 27 (ft.) Division o r 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 Inlection Neils: In addition to sending the form to the address in 24a
Air Rotary above, also submit ne copy of thisform within 30 days of completion of well
12.Well construction method: construction to the f llowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Watt r Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 13 Method of test: Air 24c,For Water Suimly&Injection' Wells: In addition to sending the fort to
the address(es) abo ie, also submit!one copy of this form within 30 days of
131b.Disinfection type: 70% HTH Amount: 12oz completion of well ronstruction to the county health department of the county
where constructed.
u
Form GW-I North Carolina Department of Environmental Quality-Division of 3 Water Resources Revised 2-22-2016
I