GW1-2022-09148_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i.Well Contractor information:
Frankie L. Oliver Y4:t4VA ti �r v t :: , ' ` • ". 4.u. = °a;
Well Cuntractvr Name FROM TO ' DESCRIPTION
128 tc. 140 n.
3002-A
165 r`' 215 n' 228
NC Well Contractor Certification Number
38 t1Ya rRRitillii-"Lt`a $'" 1 RnT71!Tplt iPd> 1$lill
Carolina Well Drilling FROM To DIAMETER THICKNESS MATERIAL.
Company Name
0 n 95 n' 10 1n' PR200 PVC
pYiC/1NN$R`l}eIiSIN n tTUf1ING" Yiip Pil °ll 'dHL8 _
2.Well Construction Permit#: 13847 FROM TO DIAMETER TMCKNESS MATEA1AL
List all applicable well cunstnection peimirs(i.e.U1C,Cuwro,State,Variance,etc.) 0 n' 120 r`' 6 5/8 In- .188 GaIv.Steel
3.Well Use(check well use):
i(hrigation
ter Supply Well: FROM TO DIAMETER St OT SIZE TRTCANFSS MATFRTAi,
gricultural ®Municipat/Public ft. n. In.
eothermal(Heating/Caoling Supply) ®Residential Water Supply(single) ri tt- in
Industrial/Commercial ®Residential Water Supply(shared)
FROM - TO MATERIAL EMKI ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rc. 2b I- n Bentonite Pour 33 501b Bags 10"
Monitoring 13Recovery 0 n' 20 r`' Bentonite Pour 27 501b Bags 6"
injection Well:
Aquifer Recharge ®Groundwater Remediation
1'siS`¢ND/GR3l �GrC t IE�,.�, :•- . ._ :F�r-��,
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMN-A CEMENTMMOD
Aquifer Teel �Stormwatet•Drainage
ft. n.
Experimental Technology Subsidence Control ft. I n.
Geothermal(Closed Loop) ®Tracer 2U;` 1tITST3IND Gqg ddt t4iTi(1'slileta 'ec
Geothermal eaLin Coolie Return) Other(explain under#21 Remarks FROM TO I DFSCRTPTION color,hardness sdUmck tam sire,etc
0 r`' 141 it, Orange Sandcla
4.Date WeIl(s)Completed: 7-27-22 Well ID# 14 r`' 99 n' Brown Sand
Sa.Well Location: 95 r`' 1 �4 n' Brown Sandstone/Gravel
Wayne Oakley 114 rc' 240 n' Granite
Facility/Owner Name Facility TD#(if applicable) tt' tt'
2680 Meadow St.Gastonia 28056 ft.
Physical Address,City,and Zip `t. ! ft
t:
Gaston 3544-34-8889
County Parcel ldentifm6un No.(PIN)
!
5b.Latitude and longitude in degreeshuinutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:'
35.13.633 81.11.830 �, 1
N
"�-;Jg(R2! 8-16-22
6.Is(are)the well(s)OPermanent or 13Temporary Signature of Catifiod Well Contractor Date
By signing this fort 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an erdsting well: ®Yes or 5114o with 1SA NCAC 02t.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
If Chit is a repair,fill nut lw»m well contiruchmt it formatirm and explain the nature of the copy of this rerrnd l is been provided to the well aaner.
repair under#21 remarks section or on the back of this form. 23.Site diagramlor additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use thejbuck of this page'tu 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.
drilled: SUBMITTAL MSTRUCTIONS
9.Total well depth below land surface: 250 (ft-) 24a, For All lis: Submit this form within 30 days of completion of well
Fnr multiple well[lilt all depthc if d(/(ererd(example-3(a)200'and 2@1001 construction to the following:
10.Static water level belnw top of casing: 22 (ft.) DivisicIn of Water Resources,Information Processing Unit,
If vmlcr level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (in.) 24b.For Tli ecti n Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit t one copy of this form within 30 days of completion of well
12.Well construction method: construction to it a following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of V later Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16 36 Mail Service Center,Raleigh,NC 27699.1636
13s.Yield(gpm) 25 Method of test: Air 24c.For Water Suvvlv&I 'ectfon Wells: In addition to sending the form to
the address(es) Bove, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 16o2 completion of. lell construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-VvW of Water Resources Revised 2-22-2016
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