GW1--02226_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver •14.WATER-ZONES,' '' << '
FROM TO DESCRIPTION
Well Contractor Name 143 ff 565 ft- i
3002-A ft. fa I l
NC Well Contractor Certification Number
"15.°OUTER CASING'(for muln•casedlwelLs)OR LINER(if applicable) _;'" ..
Carolina Well Drilling FROM TO DIAMETER; THICKNESS MATERIAL
Company Name 0 ft. t'117 f 6 1/4I ,tn. SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)'-::_ •
23-375
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Slate,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 OMunicipa1/Public ft. ft. in.
I
Geothermal(Heating/Cooling Supply) MI Residential Water Supply(single) fL ft. in.!
Industrial/Commercial OResidential Water Supply(shared)
Irrigation _FROM TO MATERIAL EMPLACEMENT METHOD At AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft Bentonite Pour(55)50Ib Bags
Monitoring DRecovery rt. rt.
Injection Well:
fL It.
Aquifer Recharge I0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)' , - '
Aquifer Storage and Recovery EISalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStoimwater Drainage ft. ft. ,
Experimental Technology DiSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2D.DRILLING LOG(attach-additianalsheets if necesy
sar). '" °'
FROM TO DESCRIPTION(color,hardness,soillruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under 4121 Remarks)
0 ft- 10 ft. Brown Clay
4.Date Well(s)Completed: 1-23-24 Well ID# 10 It. 95 It' Brown Sandclav
5a.Well Location: 95 ft 600 ft ' Blue Slate !!r.-- ,--- ,.,
ft. IL S` . ,L V a
Abraswell for Kidsprotector Inc.
Facility/Owner Name Facility ID#(if applicable) ft. ft. �j
5805 Cheraw Rd.Marshville 28103 et. rt. I
• APR
L�Z
Physical Address,City,and Zip rt. rt. I nf, iTirp £p P r-�,SyI,,;': ;UM
Union 03-087-035 .2I..REMARKS ,: s �:._: . : .'ice
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: I
35.01.753 N 80.72.374 `,F, [
,(e 2-7-24
6.Is(are)the well(s)EaPerinanent or Temporary Signature of Certified Well ContractorDate
8y signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JJYes or i No with 15A NCAC 02C.0100 or 15ANCAC,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'detai7s:
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: 600 (fir) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(eraniple:3(t_ 00'and 2(g100') construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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.) 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) 1.5 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: 70a/o HTH Amount: 36oz completion of well construction to'the county health department of the county
where constructed. I II
I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2076
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