GW1-2022-09149_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Utz Only:
1.Well Contractor Tnforination:
Frankle L.Oliver �vAatiA
Well.Contractor Name FROM TO' IPTI DESCRON
197 f` 230 n'
3002-A
243 eL n.
NC Well Contractor Certification Number � `fltlTttR" ``5.'G,fllT`tlndlii•'�(t d iVells'; R`1tlH>It t i Bee' `
Carolina Well Drilling FROM TO DIAMETER TH1CRNECS MATERIAL
0 f`' 125 n' 10 in' PR200 PVC
Company Name r` 1� C�1fiI..,t1R, TiBING3" 'tti3. °efill'_ ,
2.Well Construction Permit#• 13848 FROM TO DIAMETER THICKNESS VI MATERIAL
List all applicable well cunrnuction permits(Le.U1C,CuuntY,Stare,Variance,etc.) 0 f`- 177 f`' 6 1/4 i°' SDR21 PVC
3.Well Use(check well use): et. n. in.
Water Supply Well: 7,,S`Gi; L ., r -u`
FROM TO DTAMF`rFR STOTSI7F TRTCKNRSS MATFATAi.
Agricultural ®MtmicipaUPublic fl, ft. in.
Geothermal(Heating/Cooling Supply) BIResideutial Water Supply(single) g- in.
Industrial/Commercial 13Residential Water Supply(shared) B.--RDL, , I 1 .,,M .: �'L r
�E
Irrigation FROM To:ToL FAUI ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n- 2, + n• Bentonite Pour 28 50lb Bags 10"
Monitoring Recovery 0 n• 2' + n' Bentonite Pour 26 501b Bags 6"
injection Well:
Aquifer Recharge ®GroundwaterRemediation 1990111,41A "Cott C IfiCell
Aquifer Storage and Recovery [3Saliniry Barrier FROM To, MATrXIAL FIHPLACEMENT METH(W
Aquifer Test [3StormwaterDrainage ft. ft.
Experimental Technology Subsidence Control ft. n.
Geothermal(Closed Loop) Tracer ? G atfs3cli dStlt"`d`"irel(stltiigZP�sa
Geothermal (Heating/Cooling Return) Other(explain under*21 Remarks FROM TO TTSCRTPTION eotor,hardnmv so0h+oek tylmw,graln strc etc..
0 f`. 1 n• Orange Sandcla
4.Date Well(s)Completed: 7-20-22 Well ID# 16 f`' 1 5 f' Brown and
5a.Well Location: 125 rt. 1 5 ft' Brown n e
Wayne Oakley 165 1" 360 ft* Granite
Facility/Owner Name Facility 11M(if applicable) ( A — t `p
2676 Meadow St. Gastonia 28056 ft.
Physical Address,City,and Zip ft. n. SEP v- P 2LIZZ
Gaston 3544-34-9903 Zit:REMAR$C 4y t -
...rY s� t:rl_�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification`
35.13.638 N 81.11.820 W
..,�- 8-16-22
6.Is(are)the well(s)QPermanent or 13Temporary Signature of Catili d Well Contractor Date
Br signing this form.1 hereby cenify ihat the wetl(s)war(were)constructed in accordance
7.Is this a repair to an eldsting well: ®Yes or MNo with 15A NCAC#.0100 or 15A NCAC 02C.0200 Well Construcliun Standards and that a
If this&a repair,fill nut harm well con michnn infornuaam and explain the nature of the copy of Chit reenrd(tar been pmvided to the well natter.
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 till 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: SUBMITT L MSTRUCT IONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wks: Submit this form within 30 days of completion of well
For multiple rveliv lia all depthv it'difjerem(ex<unple-3@l200'and 2@100D construction to the following:
10.Static water level below top of casting: 25 (ft.) Divisl in of Water Resources,Information Processing Unit,
if n atcr level is above casing.use"+" 117 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Wee on Wells: In addition to sending the form to the address in 24a
Air Rotary above, also subs tit one copy of this form within 30 days of completion of well
12.Well construction method: construction to,tic following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of,I Vater Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i 4 36 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test- Air 24c.For Wate Suninly&Injection Wells: In addition to sending the form W
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 18oZ completion of ell construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Divlsiun of Water Resources Revised 2.22-2016
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