GW1--05764_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: l
1.Well Contractor information: !
1 i
Frankie L.Oliver 14.-WATER2ONE5 q, _.': _� . .S- ;, ' ,'
WellCun¢ac[orName FROM , TO DESCRIPTION
3002-A 298 ft. 367 ft, I
397 ft•. ft. I
NC Well Contractor Certification Number w 15.OUTER CASING'(for inulh cased"Wells)OR I iNER'(ifsap licable):. ,, .
Carolina Well Drilling FROM TO DIAMETER i THICKNESS - MATERIAL
Company Name 0 ft. 124 ft' 61/4 ,'n' SDR21 PVC
14049 °"'.16.;INNEI CASING OR TUBING:(geotliermal'.closed loop)i'c t, , - �., n<;
2.Well Construction Permit it: FROM TO DIAMETER, THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. ; in.
3.Well Use(check well use): It. ft• i in.
Water Supply Well17=SCREEN, ",.: ,*> .w x �«
DIAMETER• SLOT SIZE THICKNESS MATERIAL
FROM TO
Agricultural OMunicipaUPublic it. ft. in.:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,,
IndustriallCotmnercial Residential Water'Supply(shared)
"IB.,GROUT_.. �%a
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fInigation FROM TO � MATERIAL ��EMPLACEMENT ME•THOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft• Bentonite Pour(18)50Ib Bags
Monitoring EiRecovery ft. ft. '
injection Well: ft. ft.
Aquifer Recharge undwater Remediation
49 SAND/GRAVFi,:PACK(if applicabte) 4 ti 9
Aquifer Storage and Recovery Salinity Bawer FROM TO MATERIAL EMPLACEMENT METHOD
0
Aquifer TestStoriirwatei Drainage ft. ft.
Experimental Technology Groundwater Subsidence Control It. ft.
EliGeothetmal(Closed Loop) OTracer >20„DRILLINGTOG:(attackadditionatsheetsifnecessary))s ,s . . ,4 ',
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
riGeothemial(Heating/Cooling Return) Other(explain under 421 Remarks)
0 ft• 4 ft• Red Clay
4.Date Well(s)Completed: 5-31-23 Well ID# 4 ft• 118 ft' Brown Sand/Gravel
5a.Well Location: 118 ft 425 ft• Granite
Pearson Fallon ft. ft. RE
C E;•VE
Facility/Owner Name • Facility ID#(if applicable) ft ft.
1026 Old NC 27 Hwy. Mt.Holly 28120 ft. ft. ' SEP 0 1 2023
Physical Address,City,and Zip ft ft 2 < ' ,
Gaston 3597-48-5344 s^21.REMARKS ,. . { 4 =r..wLr.++Y.- Z r "-�"~ 9 Ira
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:
35.05.720 N 80.77.319 "
6-15-23
6.Is(are)the well(s)MPermanent or I Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or liallo with 15A NCAC 02C.0100 or 15A ArCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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 1 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: 425 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exrnnple-3@200'and 2i}l00') construction to the following: '
10.Static water level below top of casing: 15 (ft.) Division of Water Resoul ces,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 Injection 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
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13a.Yield(gpm) 4 Method of test: Air 24c.For Water Supply&Iniecti�n*ells: 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: 26oz completion of well construction to diecounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016