GW1--04428_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Qnly:
1.WellContractorinformation: j
1
Frankie L.Oliver r`14i;WATER=.ZONEs. ,4'.':`r .•,.'; ...t,rr. : w .. ,-,!!.'":
FROM" TO t DESCRIPTIONWeIlContracwtName 179 ft' 295 'ft.
3002-A —
319 ft' . 426 i ft' G ,
NC Well Contractar Certification Number •
''F151 OUTSI,CASiNGI(fo r.multI ciised`vells).OR I INF.R`.(Ifap lteable) .
Carolina Well Drilling FROM To 1 DIAMETER I. THICKNESS ._ - MATERIAL
Company Name
0 'IL 69 1 ft' 6 1/4 I I"' SDR21 PVC
13898 ."141 INNER';CA.SING OR T.LBINGI(geothernial dosedloop)' ,., z
2.Well Construction Permit di: FROM TO '.{ DIAMETER ' THICKNESS MATERIAL _
List all applicable well comtntctlon permits(i.e.U1C,County,State,Variance,etc.) ft.• ;l ft. in.
3.Well Use(check well use): ft. ! ft. In.
Water Supply Well:
:.17:!SCREEN :;ti . . .:; . •'<'
FROM TO ' ! DIAMETER SLOT SIZE THICKNESS MATF.RTAi.
Agricultural 0Municipal/Public ft. tt. In.
Geothemnal(Heating/Cooling Supply) 53RegdenOal Water Supply(single) ft. . IL trt,
Industrial/Commercial °Residential Water Supply(shared) '
ts1R�GROUT.. `. + :�;3` eak.c, t � ;:.:,
Inigation FROM TO l MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff 20+ ft' Bentonite Pour(18)50Ib Bags
Monitoring Recovery ft. ', ft.
injection Well:
ft, I ft,
Aquifer Recharge 0 Groundwater Remediation '
'.19.'SANG/GRAVE PACK.(Ifapplhabte) .'�'z °` w ` ,- c...
Aquifer Storage and Recovery E3Sahnity Barrier FROM TO 1 • MATERIAL • EMPL4CEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. rt.
Experimental Technology ,QSubsidence Control ft. 1 ft.
Geothermal(Closed Loop) )Tracer 20.'DDRILiLINGLOG-iattnehadditIoiiui'sheetsdf.nccessery).; ,'
FROM TO I IFSCRTPTiON(color,hardness,solWrock type,seals sue,etc.)
'Geothemmal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 4 n. Red Clay
4.Date Well(s)Completed: 3-23-23 Wel ID# 4 ft' 60 ft' Brown Sandclay
5a.Well Location: 60 ft' 450 ft' Granite t"' ^"'" 7—.
Justin Padgett ft. 1 ft' t '°'°� -.,.-.1 i l
Facility/Owner Name Facility MN(if applicable) ft. ft. J fJ11+ 2023
205 Springs Creek Dr.Mt.Holly 28120 ft. ' ft.
ft, rt. lnfci•rt-.al n Pr ,1,ti'j l rr.s
Physical Address,City,and Zip !
Gaston 3587-30-6537 ~-21 REMARKS l` .. . + ,. . ; . .c.,,, r, , ,,, .. , ,_'_
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.Certillcationi
35.29.961 N t81.06.574 �r r( 4-7-23
irate of Certified Well Contractor Date
6.Is(are)the well(s)gPermanent or OTemporary
By signing this forin,I hereby certify Mai the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IYes or Film, with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out,bourn well construction information and explain the nature of the copy of this record as been provided to the well owner.
repair under#2I 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 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. Youmay also attach additional pages if necessary.
I
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 450 .(ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells lire all depths if different(example-3(a1200'and 2(0100') construction t0 the following:
in.static water level below top of casing: 38 (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 Infection 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,cutely,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 5 Method of test: AIr 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 28oz completion of!well coustniction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Divi$ion of Water Resources Revised 2-22-2016