GW1-2022-09153_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Us Only:
1.Well Contractor information:
Frankie L.Oliver ib1Ril1I}R tl *� '. r
Well Contractor Name FROM TO DESCRIPTION
134 « 148 «
�'156o11�itl2 tsAS11�t fbr��rrdtii�$l�d°"i
ft' «.
NCC W Well ell C Convector Certification Number166 187 "' F 1 unt111(v�R°Ir I�ti1�`
Carolina Well Drilling FROM TO : DIAMETER TIUCK MESS MATERIAL
Company Name 0 « 80' 1 «' 10 in. PR200 PVC
13846 + 11: tilt MV ING � p ti
2.Well Construction Permit#• FROM I TO; DIAMETER I IMCKNESS MATERIAL
List all applicable[vell consnucdon pernsUs(i.e.UIC,County,State,Variance,etc.) 0 «' 128 «' 6 1/4 i ' I SDR21 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: FROM TO niAMF"rm SLOT S17,F, TmCKNFSS I MATERIAL
Agricultural ®Municipal/Public «• «• In.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) In
Industrial./Commercial [31tes;idential Water Supply(shared)
Irrigation FROM TO MATERIAL EWI ACFM&NT METHOD&AMOUNT Y
Non-Water Supply Well: 0 «' 26 « Benton
ite Pour 38 501b Bags 10"
Monitoring Recovery 0 It. 20 «• Bentonite Pour 31 501b Bags 6"
injection Well: If. I ft.
Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery Salmi Barrier
9 g H'Y � tY FROM TO'+ MATERIAL EMP44tL7_AtFdNT METHe ID
Aquifer Text 13Stormwater Drainage «- rL
Experimental Technology [3SubsidenceControl ft. ft.
Geothermal(Closed Loop) ®Tracer ,-(1° RME11N 0 'aVttg&'Wd!"Onill sb fl'Itiie {s F ut:;
Geothermal (Heating/Cooling Return Other(explain tinder 421 Remarks) FROM TO I nvscRTmoN color,hardness aoil/rock tytm jtmtn s[u etc
0 «• 17 ft Oran a Sandcla
4.Date Well(s)Completed: 8-2-22 well lD# 17 ft' 8 «' Brown Sand
5a.Well Location: 80 «• 1 0 It. Brown Sandstone/Gramel
ft �.
Wayne Oakley 120 2 «,0 Granite
Facility/Owner Name Facility ID#(if applicable) ft. «.
2684 Meadow St. Gastonia 28056 HE
Physical Address,City,and Zip
rt. «. `
Gaston 3544-34-8874
County Parcel identification No.(PIN)
5b.Latitude and longitude in degreeshninutesAeconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification
35.13.621 N 81.11.834
8-16-22
Signature of Certifiul of Well Contractor Date
6.Is(are)the wells)JaPermanent or [3Temporary i
AV signing this for i I hereby ceniio-that the well(s)was(were)consirucled in accordance
7.Is this a repair to an existing well: ®Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conatruchon Standards and that a
If this it a repair,fill out knoun well constructinn h1formatirm and explain the nature of the copy of Chit reenrd inn been provided to the well owner.
repair ender#21 remarks section or on the back of this form. 23.Site diagram'or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the Iback of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITT�'RUC'fIONS
9.Total well depth below land surface: 200 (ft-) 24a. For All pis: Submit this form within 30 days of completion of well
For multiple runic list all deptkt if different(ex<nmple-3@200'and 2(af)001 construction to the following:
10.Static water level below top of casing: 24 (ft.) Division of Water Resources,Information Processing Unit
1/wirer level is above casing,use"+" 16 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (�•) 24b.For ectl to Wells: In addition to sending the form to the address in 24a
Air Rotary above, also subulit one copy of this form within 30 days of completion of wel I
12.Well construction method: construction to the following:
(i.e.ergo,rotary,cable,Direct push,etc.) II
Division of W�'ater Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1686 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 25 Method of test: Air 24c.For Waterisupply&Irijection Wells: In addition to sending the form to
the address(es) ftbove, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oZ completion of well construction to the county health department of the county
where construcic d.
Form GW-1 North Carolina Department of Environmental Quality-Divlcior of Water Recour i Revised 2-22-2016
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