GW1--05097_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
158 ft. 185 ft-
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 LL4METER THICKNESS NI tTERIAL
0 ft. 45 ft' 61/4 D7' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 14333 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc.) rt. ft. in.
3.Well Use(check well use): ft. ft. i°'
Water Supply Well: 17.SCREEN
FROM TO DLSMETEl1 SLOT SIZE THICKNESS N ATERI.:II.
®Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Ea Residential Water Supply(single) ft. ft. in.
Industria1JCommercial Residential Water Supply(shared) ts.GROUT
Irrigation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(15)50Ib Bags
°Monitoring DRecovery ft. ft.
Injection Well: rr. eL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()3ahnity Barrier FROM
ft. TO MTERIAL. EMPLACEMENT METHOD
Aquifer Test ()Stormwater Drainage ft. A
Experimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION icolur,hardness,soil/rock type,grain size,etc.)
()Geothermal(Heating/Cooling Return) [-]Other(explain under#2I Remarks 1
0 ft- 6 ft. Red Clay
4.Date Well(s)Completed: 6-28-24 Well ID# 6 It. 28 It. Brown Clay
5a.WellLocation: 28 ft- 225 ft. Granite --
Koval Builders ft.. tt' `-4. i;:;Li
Facility/Owner Name Facility ID#(if applicable)
ft
" AUG 2 7 20?4
2336 Old NC 27 Hwy Mt.Holly 28120 ft. ft.
It. ft.
Physical Address,City,and Zip
Gaston 3588-38-2082 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.35.033 N 81.07.317 W C:>1 ( b _,a, 7-23-23
6.Is(are)the well(s)�Pennanent or Temporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or MNo with 15A 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 1121 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 welldepth below land surface: 225
(R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nutltiple wells list all depths if different(example-3(d 200'and 2@100) construction to the following:
10.Static water level below top of casing: 22 (ft.) Division of Water Resources,Information Processing Unit,
1f 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) 13 Method of test: Air 24c.For Water Supply&injection Wells: in addition to sending the form to
0
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 14oz 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