GW1--00927_Well Construction - GW1_20240209

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES, '-
Well Contractor Name FROM TO DESCRIPTION
3002-A 55 rt. 125 f` I
144 f` 163 f` I .
NC Well Contractor Certification Number 15:OUTER CASING(for multi-eased-wells)OR LINER(if applicable).
Carolina Well Drilling FROM TO DIAMETER , THICKNESS MATERIAL
0 f` 43 f` 61/4I in' SDR21 PVC
Company Name -16.INNER CASING OR TUBING(geothermal closed-loop)'r :.''
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U/C,County,Stare,Variance,etc.) rt. ft. i in.
3.Well Use(check well use): ft ft in
Water Supply Well:
17.SCREEN ,'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. it. in.
Industrial/Commercial 0 Residential Water Supply(shared) :18.GROUT . - s'`
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 20+ f` Bentonite Pour(14)50Ib Bags
Monitoring IDI, Recovery ft. fe
Injection Well: fc. ft.
Aquifer Recharge I0Groundwater Remediation
'19.SAND/GRAVEL PACK(if applicable),
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStornwater Drainage rt. rt.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)_
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,suiVruck type grain size,etc.)
0 f` 6 f` Brown.Clay
4.Date Well(s)Completed: 1-3-24 Well ID# 6 f` 12 f` Red Clay
5a.Well Location: 12 ft 30 ft- White Clay
VPTP Poultry LLC Deep Creek Farm Well#2 30 f` 38 f` Grey Clay ,.,_ 4.4,7--t% 6 t... '.
Facility/Owner Name Facility ID#(if applicable) 38 ft- 400 ft- Granite e, L�..i V Lo
DeepCreek Rd.Wadesboro 28170 rt. ft. 1
. F H 3 9 9 2024
Physical Address,City,and Zip ft ft.
Anson N/A 21.REMARKS •
tiVIC;f3t tell,rrv.4414141 Up+:+:
DwQ/aO
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:
34.50.838 Nm 80.70.056 `jt
1-22-24
6.Is(are)the well(s)0Permanent or oTemporary Signature of Certified Well Contractor Date
By signing this form, 7 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes or y!alNo with ISA NCAC 02C.0100 or 15ANCAC;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 o f 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 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/It list all depths if different(example-3g:200'and 2@100') construction to the following:
1
10.Static water level below top of casing: 20 (ft) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1 61 7
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:
(i.e.auger,rotary,cable,direct push,etc.) J
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply&intection 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:__ 2402 completion of well construction to the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016
I