GW1--05093_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
330 R. ft-
3002-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(fur multi-cased wells)OR LINER(if a Ilcable)
Carolina Well Drilling FROM TO I UTANIETER THICKNESS MATERIAL.
Company Name 0 n' 180 n' 61/4 113' SDR21 PVC
13832 16.INNER CASING OR TUBING(geothermal closed-loop)
A
2 Well Construction Permit#: FROM TO ULAMETER THICKNESS MTERIAL.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc 1 ft. ft. in.
3.Well Use(check well use): ft [t in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
▪Agricultural DMunicipalfPublic ft. ft. in.
O Geothetmal(Heating/Cooling Supply) EaResidential Water Supply(single) ft. ft. in.
0Industrial/Commercial nResidential Water Supply(shared) t>r.GROUT
0 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD St tMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(40)501b Bags
13Monitoring ORecovety ft. et.
Injection Well: ft. it
OAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery I3salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
aquifer Test �Stotmwater Drainage ft. I t.
Experimental Technology Subsidence Control fc. It.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM [ Tl1 DESCRIPTION(color,hardness,soil/ruck type,grain s1ze,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#2l Remarks)
0 ft- 40 11- Brown Clay
4.[)ate Wells)Completed: 6-18-24 Well ID# 40 ft- 173 f1' Shale Rock(Brown,Grav)
5a.Well Location: 173 ft. 345 ft- Granite
Frank Eshun rt rt. • , . : : -
' 6
Facility/Owner Name Facility ID#(if applicable) ft. ft.
311 Pinnacle Rd. Kings Mountain 28086
ft- ft. ? ZOZ4
Physical Address,City,and Zip ft. ft
Gaston 3513-23-4642 21.REMARKS i s;,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Lit/long is sufficient) 22.Certification:
35.19.473 N 81.30.176 W
6-24-24
6.Istare)the well(s)10Pertnanent or )Temporary Signature of Certified Contractor Date
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or tallo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standarde and that a
If thus 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 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depthr if different(example-3(J200'and 2Q100') construction to the following:
10.Static water level below top of casing: 85 (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 torn 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) 100 Method of test: Air 24c.For Water Sunnly & inlection 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 at Environmental Quality-Division of Water Resources Revised 2-22-2016