GW1--07938_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES' ; °.ti1,`,.: .- •
Well Contractor Name FROM TO DESCRIPTION
3002-A 93 EL 190 ft I
267 ft ft I '
NC Well Contractor Certification Number 15..OUTER>CASING.(for multi-cased:wells),OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 65 ft 6 1)4 tn' SDR21 PVC
Company Name -16.,INNER CASING OR''I ING•(geothernial closed loop), . '
2.Well Construction Permit#: 14195 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft j in-
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN �_"
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. it. in.
Geothermal(Heating/Cooling.Supply). r4'Residential Water Supply(single). ., ft.' - ft. • in. ,. .
Industrial/Commercial DResidential Water Supply(shared) -18.GROUT. '` '
Irrigation FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ et Bentonite Pour(15)50Ib Bags
Monitoring DRecovety ft ft
Injection Well:
ft it.
Aquifer Recharge I0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Ell SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test .fStomtwater Drainage It it.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .20.1)RILLING LOG-'(attach additional sheets if necessary) . '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,suil/rock type,grain size,etc.)
0 et 6 ft Red Clay
4.Date Well(s)Completed: 10-3-23 Well ID# 6 ft 14 ft Brown Clay/Gravel
5a.Well Location: 14 ft 55 ft Brown Sandclay
Justin Padgett 55 ft 300 ft Granite r,'�• i ,i -il '(,f F""
Facility/Owner Name Facility BM(if applicable) ft. it
219 Spring Creek Dr. Mt.Holly 28120 et et DEC 0 8 2023
Physical Address,City,and Zip ft' ft Inftr,G%�1tCn Pr cws-4:te U�
Gaston 3587-31-6041 m.2I.:REMARKSz--= . . � , DV= ,.t12.0i3
County Parcel Identification No.(PIN) -
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.30.1-07 N 81.06.564 `l,
;�' 10-16-23
Temporary Signature of Certified Well Contractor' Date
6.Is(are)the well(s)10Permanent or
13v signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or j!j No with ISA NCAC 02C.0100 or 1SANCAC 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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3t z 00'and 2Q100') construction to the following:
10.Static water level below top of casing: 26 (ft.) Division of Water Resources,Information Processing Unit,
Tfwater 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 farm 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,ere:) '
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 38 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: 18Oz completion of well construction Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016