GW1-2022-08535_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14 WATExZONEs°
Well Contractor Name FROM TO DESCRIPTION
ft. ft. �
A - 4459 ft. ft.
NC Well Contractor Certification Number 15.`OUTER CASING-(for rmulN-cased wells OR'LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in
Company Name
16:INNER CASING,OR'TUIIING, 'eothermal'closed-loo A 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 fi- 5.0 ft. 1.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: `47.SCREEN,","
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 It' 15.0 ft' 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft: in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18 GGROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 It' PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
193SANDIGRACEL PACK if a 'licable : -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 It. 15.0 If. 20-40 FINE SILICA SAND
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'additionalsheetsif necessa' -
❑Geothermal(Heating/Cooling Return) El Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soillnek type rain sin,etc.
0.0 It. 15.0 It. SILTY CLAY
4.Date Well(s)Completed: 04/19/22 Well ID# LFG-32 ft. ft.
5a.Well Location: ft. ft.
PLEASANT RIDGE SCHOOL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1260 FLOYD LANE GASTONIA 28052 ft. ft.
Physical Address,City,and Zip ft. ft.
�21Y`REMARKS .=
GASTON
County Parcel Identification No.(PIN) BENTONIfE SEAL-2.0-4.0 FEET
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***LANDFILL GAS PROBE***
(if well field,one Iattlong is sufficient) 22.Certification:
350 15' 00.88" N 810 12' 20.73" W �2 , �
04/25/22
6.Is(are)the well(s): 29Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this,is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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 vrA c truction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You may also attach additigges if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
1 �/ 7 `�9.Total well depth below land surface: 1 5'� (ft.) B p 2 20=�
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completilu l r the following:
10.Static water level below top of casing• (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 2.25 (in.) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HAND AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018