GW1--07960_Well Construction - GW1_20231208

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
Frankie L.Oliver t.14:WATER ZONES,,'., .,t..:
FROM TO DESCRIPTION
Well Contractor Name
3002-A 52,66 EL 105 f` I
145 f[. 230 f[.
NC Well Contractor Certification Number "15:.OUTER CASING(for u ulti•cased wells)OR LINER(if applicable) - ,
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 48 ft- 61/4 in* SDR21 PVC
,:=16:INNER.CASING:OR TUBING'(geotherinal''dosed-loop).
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Stare,Variance,etc.) ft. ft. , in.
3.Well Use(check well use): ft ft in.
`17;.SGREEN... . i. "r - +-; r , ,•, - .,,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Ij Municipal/Public ft. ft. ia;
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial
Irrigation
ft. ft. in:
Residendal Water Supply(shared) :IS;GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft" 20+ ft- Bentonite Pour(28)50Ib Bags
Monitoring
IRecovety ft ft
Injection Well: f[ rt.
Aquifer Recharge IDGroundwater Remediation - .
19:+SAND/GRAVEL PACR;(ir applicable)." *: '
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft.
ExperimentalIi
Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer +.20:DRILLING,LOG(attach additional sheets:if necessary)' ; ' "r- '' -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sml/ruck type,grain size,etc.)
0 ft. 20 IL Orange Sandclay
4.Date Well(s)Completed: 10-19-23 Well ID# Well#5 20 It' 300 FL Granite
ft. ft-
5a.Well Location:
Lucky Family Farm ft. ft. 1 -
Facility/Owner Name Facility lD#(if applicable) ft ft ! t ..i—s ,,,,r L.:tz tti L.J`
5888 Hwy. 742 South Wadesboro 28170 ft. ft. Q
Physical Address,City,and Zip ft Ft Dr t, O 21)'j
Anson N/A 1i21..i2EMARKS.,w" ;k.'f,' ''S r , ;r1:,.y 2 •:lfn !)A:j,Ui`. .,
DWQ/3rOG
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:
34.88.327 N 80.09.543 W f'�d
11-3-23
6.Is(are)the well(s)MPertnanent or Temporary Signature of Certified Wei
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: jYes or Zi No with ISA 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 etplain the nature of the copy of this record has been provided ta,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
For multiple wells list all depths if different(example-3 Fc200'and 2Q100) construction to the following:
10.Static water level below top of casing: 21 (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 form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(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) 22 Method of test: Air 24c.For Water Supply&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: 18oz completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016