GW1--00917_Well Construction - GW1_20240209

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: • '
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1.Well Contractor Information: ,
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Frankie L.Oliver I :14'WATERZONES 'rIEV?'k . .', *'.. . `li?a _ . -:: 3 ,,•":, a';,
Well Contractor Name 1 FROM TO DESCRIPTION
3002-A •
91 ft- 167 ft- 1
192 et. 'ft.
NC Well Contractor Certification Number
c:15:01.ITER-CASIN'GAroc.nmitl`cnse'd4clts)I(IRLINEROfappl(cab10: `ti s:' , ,;z
:Carolina Well Drilling ! FROM TO • . DIAMETER THICKNESS MATERIAL
Company Name ! 0 ft. 20 ft. : 10 !.In', SDR21 PVC
'A'6ANNF.R,CASING',ORSTUBINGItkentlieriilittelose'd4inni):" �c . ? .,
N/A $. ..
2.Well Construction Permit#: I FROM TO ' DIAMETER ' THICKNESS MATERIAL
List all applicable well construction permits VIC,County,State,Variance,etc.) 0 R• 72 rt' 6 1/4 I In' SDR21 PVC
3.Well Use(check well use): (i.e.I( ft. ft. i in.
I Water Supply Well: ' 17.`SCREEy 'W.X, a- .. : ) 'nzf ,i l.r.;; . t'W: ,. •1, t N'z....`u
FROM TO ' DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. 1 in.
Geothermal(Heating/Cooling Supply DResidential Water Supply(single) fL ' ft. 1 in.
Industria l/Commercial Residential Water Supply(shared) .
F.,.p pP Y r'.lR3'GR�OUT . . �, , 1 K:-r,{i;, < .p. : r'•' z�r>,,
Irrigation j FROM TO' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 0 fL 20+ fL Bentonite Pour(12)501b Bags(6")
Monitoring 11 ORecevery
0 fL 20 IL Bentonite Pour(8)501b Bags(10")
Injection Well: ! ft. fL
Aquifer Recharge ` 9Groundwater Remediation
,l'A9:SAND/GR'AVEf-i ACK_(tf it/01161)/1W'a,-„v4 i. .!'.,.w.i c :r, .,`"a „ f..e
Aquifer Storage and Recovery Salinity Barrier FROM TO' MATERIAL EMPLACEMENT METHOD
Aquifer Test f DStormwater Drainage rt. rt.
Experimental Technology E3Subsidence Control ft. ft •
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Geothermal(Closed Loop) E3Tracer k;a;2Q}DRILLINGIiOGIattaehaddltinnaisbeetsiriiecessury)Fri YW:13r?. ':
i FROM TO' DESCRIPTION(color,hardness,soNrock type,gniln die,etc.)
Geothermal(Heating/Cooling Return) }Other(explain under#21 Remarks)
0 ft- 8 fL Brown Sand
4.Date Well(s)Completed: 1-11-24 Well ID# 8 It' 20 ft' White/Pink Sand
5a.Well Location: 20 ft' 45 EL Browntlav
Anh Le 'Cason Farm LLC Well#1 45 ft• 55 IL White Clay _ fp,. ef.,,.7".'? �.
Vet::LL$\/L
Facility/Owner Name r 'Facility ID#(if applicable) 55 iL 65 iL Grey Clay [ "�
3011 Cason Oidfield Rd. NlnlNvt:rh 2ghiq 65 fL 300 ft- Granite FEB e 5 9024
Physical Address,City,and Zip ft.
.N/A rf21 REMARKS%s-J�Y.f.t..,,,-.9;1i,f( SYt'r ..t'.. , .,',iR of i't riA;!i^ y..Vt,
Anson 1 n''
DiilairsOU
'County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latfong is sufficient) 22.Certification:
34.49.814 N 80.40.802 ,
1-22-24
6.Is(are)the wel1(s)MPerrnanent or Temporary Signature of Certified Nell Contractor Date
By signing this for.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or f a'No wills ISA NCAC 02C.0100 or 15A NCACO2C.0200 Well Construction Standards and that a
if this is a relate;fill oat known well construction informationand explain the ttcuure 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 ('L) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if din fareru(example-3@Z00'and 2(41100') construction to the following:
10.Static water level below top of casing: 29 (it-) Divtslon or Water Resources,Information Processing Unit,
If water level is above casing,use.•'+•• I 1617 Mail Service Center,Raleigh,NC 27699.1617
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11.Borehole diameter: 6 (In.) 24b.For Injection Wells: In adtliuon to sending the form to the address in 24a
I 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS QNLY: 1636 Mail Service Coster,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 it Method of test: Air. 24c.For Water Suirly&Infection Wells: In addition to sending the form to
the address(e$) above, also submitlone copy of this form within 30 days of
13b.Disinfection type: 70% HT1-1 Amount: 18oz completion of well construction to the county health department of the county
where constructed. J
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources r Revised 2-22-2016