GW1-2022-08555_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14::wATERZONES..
FROM TO DESCRIPTION
Well Contractor Name
70 ft. 74
85 ft.
3002-A ft. 93 '1-
NC Well Contractor Certification Number ;l&OUTER CASING(foc mt lti-cased:wells}OR LINER(if a"livable)
Carolina Well Drilling FROM I TO I DIAMETER THICKNESS I MATERIAL
Company Name 0 ft' 1 67 ft. 6 5/8 1D' .188 Galv.Steel
13504 16;INNER CASING`OR.TUBING eatWrmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructions pernnits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): et. ft. in.
17.;SEREEW":' a=;:'•
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [IMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) _18.:GROUT'
IIil a[lOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 et. 20+ "' Bentonite Pour(69)501b Bags
Monitoring DRecovery ft. ft.
Injection Well: M ft.
Aquifer Recharge OGroundwater Remediation
19.SANDIGRAVEI:PACK(if applicable)-• "'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
—!Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING T OG(attachaddidonsd sheets ifnecessar
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type, m size,etc.)
0 et' 16 rf Red Clay
4.Date Well(s)Completed:3-8-2022 Well ID# 16 rt' 30 rt' Brown Sand/Gravel
5a.Well Location: 30 ft. 57 rt. Brown Rock
Justin Padgett 57 ft' 125 rL Granite
fY -
Facility/Owner Name Facility ID#(if applicable) ft. `
5155 Stockbridge Dr. Mt. Holly 28120 Stockbridge Estates#46 ft. ft 6 20 9
Physical Address,City,and Zip ft. ft. ,
Gaston 3598-26-3070 21.REMARK5
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:
35.34.339 N 81.03.723 W
3-17-2022
6.Is(are)the well(s)&Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this fonn, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or WNo xyith 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 i»fonnation and explain the nature of the copy of this record has been provided to the well owner.
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-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: 125 (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: 34 (ft.) 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 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) 75 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 fount 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