GW1--05098_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
3002-A 235 ft. 255 ft.
et. et.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 75 ft. 6 5/8 in' .188 Galv. Steel
14272 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. tn.
3.Well Use(check well use): ft. ft is
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Agricultural QMunicipal/Public ft. rt. in.
0 Geothermal(Heating/Cooling Supply) giResidential Water Supply(single) It. it. in.
Q lndustriaUCommercial ()Residential Water Supply(shared) Ito.GROUT
1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20+ ft' Bentonite Pour(118)50Ib Bags
Monitoring D Recovery ft. ft.
Injection Well: —
fi. ft.
0 Aquifer Recharge °Groundwater Remediation
—
19.SAND/GRAVEL PACK(if applicable)
()Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage It. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION i color,hardness,soil/ruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 5 ft Red Clay
4.Date Welts)Completed: 7-1-24 Well ID# 5 II. 55 IL Brown Sanclay/Gravel
5a.Well Location: 55 ft' 400 it- Granite
Thomas Ashcraft ft. R. , ,
Facility/Owner Name Facility ID#(if applicable) it It.
8560 Catawba Cove Dr. Belmont 28012 ft. ft. °I IG 2 7 2024
Physical Address,City,and Zip ft. rt.
Gaston 3572900808 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:
35.90.856 N 81.40.688 W c:-. :: •,0 ...,,L3
7-23-23
6.Is(are)the wells) 7,Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the nell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 12.1No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ithis 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: 400 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-36200'and 2Q100') construction to the following:
10.Static water level below top of casing: 46 (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) 7 Method of test: Air 24c.For Water Supply& 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: 24oz 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