GW1--03613_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM T(1 DESCRIPTION
Well Contractor Name
112 It 115 ft.
3002-A
231 ft' 234 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 80 ft. 61/4 in' SDR21 PVC
Company Name
14209 16.INNER CASING OR TUBING(geothermal closed•loopl
2.Well Construction Permit it: FROM TO DIAMETER THICKNESS M ATEHIAL
List all applicable urnconstruction permits(ie.WC,County,State,Variance,etc.) ft. ft. In.
Well Use(check well use): ft. ft in
17.SCREEN
Water Supply Well:
PP y FROM 'f0 DI MFTEH SLOT SIZE THICKNESS hl.-1"1'E:RL4I.
°Agricultural DMunicipal/Public ft. D. in.
©Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Olndustrial/Commercial DResidential Water Supply(shared, 18.GROUT
°Irrigation FROM TO M:tTFRI1L F,MPI,'t(TALENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20+ tt' Bentonite Pour(29)501b Bags
Monitoring °Recovery it. It.
Injection Well:
ft. ft.
°Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK Of applicable)
°Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test jStormwater Drainage 1 t. It.
°Experimental Technology DSubsidcnce Control ft. ft.
°Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
°Geothermal(Heating/Cooling Return) [-]Other(explain under#21 Remarks)
0 ft. 28 ft. Red Clay
4.Date Well(s)Completed: 4-5-24 Well IDi( 28 It' 43 IL Brown Dirt
5a.Well Location: 43 ft' 74 ft. White Sandstone
Koval Builders 74 ft. 250 ft Granite._ —...1 a
Facility/Owner Name Facility ID#(if applicable) ft. iu I%`la`� f t it
208 Morris Farm Rd. Stanley 28164 rt. rt. JUN 1 i 2024
Physical Address,City,and Zip f[ ft
Gaston 3579-91-5366 21.REMARKS ►rdtsrs.&A t: . .: ,.
D't1C4 3(:ni
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or dedinal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
35.35.512 N 81.08.566 `,ire ` _ —
�m� 4-24-24
6.Is(are)the well(s)MPennanent or Temporary Signature of Certified Well Contractor Date
By signing this,form.1 hereby centfy that the wrU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or sallo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out know~(well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2l 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: 250 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wells list all depths if different(example-3 200'and 2@l00') construction to the following:
10.Static water level below top of casing: 28 (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.l 24b.For Infection 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
13a.Yield(gpm) 45 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: 15oz 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 Revised 2-22-2016