GW1--05096_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
235 ft- rt.
3002-A
ft. et.
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. 140 ft. 61/4 i"• SDR21 PVC
13830 16.INNER CASING OR TUBING(geotherm al closed-loop)
2.Well Construction Permit# FROM TO DIAMETER 1'It IC it ESS MATERIAL.
List all applicable well construction 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural °Municipal/Public ft. ft. in.
©Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. to
O IndustriaUCommercial °Residential Water Supply(shared) tit,GROUT
°Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 20+ ft* Bentonite Pour(30)501b Bags
QMonitoring °Recovery ft. ft.
Injection Well:
fG It.
°Aquifer Recharge °Groundwater Remediation —
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage It. It.
Experimental Technology °Subsidence Control ft. et.
Geothermal(Closed Loop) QTiacer 20.DRILLING LOG!attach additional sheets if necessary)
F01\1 TO DISCRI PT ION icolor,hardness,soil/rock type,grain size,etc.
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 n. 45 f`' Brown Clay
4.Date Wells)Completed: 6-18-24 Well ID# 45 "' 132 "' Shale Rock (Brown,Gray)'
5a.Well Location: 132 f`' 250 ft- Granite
rt. fL S t J
Frank Eshun • ••• �> I, i
Facility/Owner Name Facility ID#(if applicable) ft. ft.
AUG 2 7 2021
319 Pinnacle Rd. Kings Mountain 28086 6- n-
Physical Address,City,and Zip rt. ft. `= '
Gaston 3513-23-3613 21.REMARKS —
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.19.477 N 81.30.230
6-24-24
6.Is(are)the well(s)63Permanent or 0Temporary Signature of Certified Well Contractor Date
By signing this form, I hereby cert{(y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or SiNo with 15A NCAC 02C.0100 or 15A 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: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .9148 J ( •) 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 2@100) construction to the following:
10.Static water level below top of casing: 82 (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 Iniection 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) 5 Method or test: Air 24c.For Water Sunuly & 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: 16oz 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