GW1--07937_Well Construction - GW1_20231208

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.Well Contractor Information:
,
Frankie L.Oliver I'.,WATER ZONES : _ � '.° , s , _
FROM TO DESCRIPTION
Well Contractor Name
3002-A 88 ft' 162 ft'
ft. ft.
NC Well Contractor Certification Number :`1S:OUTER,.CASING(formutti,cased wells),OR';LINER^.(if applicable)- '
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 62 ft' 61,/41 tn• SDR21 PVC
Company Name ,-16.INNER CASING OR TUBING(ieotherm'al`closeddoop),„,
2.Well Construction Permit#: 14025 FROM TO 'DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UUC,County,State,Variance,etc.) ft. ft. j ' in-
.3.Well Use(check well use): ftft ' in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.'
Geothermal(Heating/Cooling Supply) MiResidential Water Supply(single) ft. ft. in.
Industrial/Commercial IDResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft- Bentonite Pour(24.5)50Ib Bags
Monitoring DRecovery ft. ft. 1
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation wry'SAND/GRAVEL'PACK(if applicable) " _"
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IIStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer •-°20_"DRILLING LOG(attach additional sheets if necessary) _ ,x,t'
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft- 10 ft- Red Clay
4.Date Well(s)Completed: 10-27-23 Well 1D# 10 ft" 25 ft. Brown Sandclav
5a.Well Location: 25 ft. 55 ft- Brown Rock
Scott&Teresa Rothenberg 55 et• 200 ft' Granite
3Facility (ifapplicable) rt it w_ 't,p I Y t 4
Facility/Owner Name ID# a licable
8469 Catawba Cove Rd.Belmont 28012 ft. ft "✓
Physical Address,City,and Zip fG fL DF t. [e[3
Gaston 3581-09-8858 •21.REMARKS ,. G,. ` y l,•v
ri'�„ r Krs
County Parcel Identification No.(PIN) 1 DVv WI 3 OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.90.406 N 81.40.155 W
11-7-23
6.Is(are)the well(s)MPertnanent or 0Temporary Signature of Certified Well Contractor Date
By signing this,form, 1 hereby certify;that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: •DYes or A'No with ISA NCAC 02C.0100 or I5ANCAC 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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
' For multiple wells list all depths if different(example-3( 00'and 2@I00') construction to the following: 1'
10.Static water level below top of casing: 34 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27 699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In audition 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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 17 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: 12oZ completion of well construction)to the county health department of the county
where constructed.
•
Form GW-1 North Carolina Department of Environmental Quality-Division otWater Resources; Revised 2-22-2016