GW1--05094_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
241 ft. 278 ft.
3002-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Ifor multi-eased wells)OR LINER if ap cable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 235 ft. 6 5/8 fn' .188 Steel
Company Name
13834 16.INNER CASING OR TUBING(geotherm al closed-loop)
2 Well Construction Permit#: FROM TO DIAMF:TF.R THICKNESS MATERIAL
List all applicable nrll construction permits(ie.WC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
©Agricultural DMunicipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ft. ft. in.
a Industrial/Commercial DResidential Water Supply(shared) IN.GROUT
0 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(67)501b Bags
°Monitoring DRecovety ft. ft.
Injection Well:
rL it.
°Aquifer Recharge DGroundwatcr Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage rL rt.
Experimental Technology DSubsidence Control ft. ft
(.isothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TODESCRIPTION'color,hardness,soiVrock type,grain sin:,ete.1
Geothermal(Heating/Cooling Return) DOther(explain under#2I Remarks)
0 ft. 70 fL Brown Clay
4.Date Wells)Completed: 5 21-24 Well ID# 70 It. 230 II' Shale Rock (Brown,Gray.Blue)
5a.Well Location: 235 ft. 250 it Granite
Frank Eshun 250 II' 295 It' Soft Granite (Blue,Brown)
Facility/Owner Name Facility ID#(if applicable) 295 it 300 It. Granite
301 Pinnacle Rd. Kings Mountain 28086 ft. ft. � .. ' •' :
Physical Address,City,and Zip rt. It. 2 ` 2024
Gaston 3513-23-6589 21.REMARKS
County Parcel Identification No.(PIN) Ir,`.:,?',; 7)- J ,-3
��4
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.19.425 N 81.30.081 W C.. ^
�,yv�[ c� 6-13-24
6.Is(are)the well(s)10Perntanent or 0Temporary Signature of Certified Well Contractor Date
By signing this,form,1 hereby certify that the neU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or EINo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair,fill out brow+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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far nudtiple wells list all depths if different(example-3td,200'and2Q100') construction to the following:
10.Static water level below top of casing: 75 (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.i 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) 20 Method of test: Air 24c.For Water Supply&iniection 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: 18oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmcntal Quality-Division of Water Resources Revised 2-22-2016