GW1--05092_Well Construction - GW1_20240827

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
321 ft. rt.
3002-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 300 ft- 6 5/8 in' .1 88 Steel
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 13833 FMATERIAL
ROM TO DIAMETER THICKNESS
List all applicable well conrrnrction 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
pp yFROM TO DI:%MF.TER SLOT SIZE THICKNESS MATERIAL
®Agricultural DMunicipal/Public rt. ft. in.
Geothermal(Heating/Cooling Supply) riaResidential Water Supply(single) It. ft. in.
DIndustrial/Commercial (Residential Water Supply(shared) 1$.GROUT
'"]Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft Bentonite Pour(84)50Ib Bags
Monitoring DRecovety ft. rt.
Injection Well: ft.
0 Aquifer Recharge 0GroundwaterRemediation 19.SAND/GRAVEL PACK(If applicable)
QAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) El 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION icolor,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft- 15 ft- Brown Clay
4.Date Weil(s)Completed: -23-24 Well ID# 15 I`' 290 It' Shale Rock (Brown,Gray.Blue)
5a.Well Location: 290 ft- 345 ft. Granite
Frank Eshun rt rt.
,
Facility/Owner Name Facility ID#(if applicable) It. It.
307 Pinnacle Rd. Kings Mountain 28086 rt. ft. 2024
Physical Address,City,and Zip ft. ft.
Gaston 3513-23-5681 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
34.19.450 N 81.30.107 `,lr ✓) O . d�
Qd 6-13-24
6.Is(are)the well(s)laPennanent or DTelnporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or MNo with ISA NCAC 02C.0100 or ISA NCAC 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: 345 (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 77 (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 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) 10 Method of test: Air 24c.For Water Sunuly& Infection 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: 22oz 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