GW1--07939_Well Construction - GW1_20231208

I
WELL CONSTRUCTION'RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
r
Frankie L.Oliver ' 14,WATER ZONES - '
FROM TO DESCRIPTION
Well Contractor Name
3002-A 62 ft. 371 ft
526 ft. ft. `
NC Well Contractor Certification Number ;15.OUTER',CASING ffor vttjlti:cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 It' 57 ft- 61/4 in' SDR21 PVC
16.)INNER CASING OR TUBING•(geothermal closed=loop)
14035
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 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. ft. in.
Geothermal(Heating/Cooling Supply') MI 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 fr. 20+ ft. Bentonite Pour(13)50Ib Bags
Monitoring - Ij Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge '❑'Groundwater Remediation
19.SAND/GRAVEL PACK•(if applicable)
Aquifer Storage and Recovery 'OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IJStomtwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft- fL ,
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)' _ ,
FROM TO DESCRIPTION(color,hardness,suil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) (Other(explain under#2l Remarks)
0 ft. 6 et. Red/Brown Clay
4.Date Well(s)Completed: 10-9-23 Well ID# 6 ft. 42 ft' Brown Clay
5a.Well Location: 42 ft. 500 ft. Granite
Justin Padgett ft ft.
Facility/Owner Name Facility ID#(if applicable) et ft. ",y'= .Kam' y %,1 1,
Dutchman Dr. Mt.Holly 28120 ft. ft-
Physical Address,City,and Zip Ft' ft k: V 8 L nL 3
Gaston 3599-27-8052 21.REMARKS ,
County Parcel Identification No.(PIN) DI`:Clt5'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.34.073 81.00.391 N W fr., /.._ 11
10-16-23
6.Is(are)the well(s)EaPennanent or DTeinporary Signature of Certified Well onu'actari Irate
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: %Yes or ONo with 15A NCAC 02C,W 00 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff 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: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3g200'and 2Q100') construction to the following:
10.Static water level below top of casing: 23 (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 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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service iCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply &injection Wells: In addition to sending the form to
the address(es) above, also subinii one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 30oz completion of well construction to,the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016