GW1-2023-00100_Well Construction - GW1_20230106

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2023-00100
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Travis Frazier [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2610 A BOBBY ALLRED, II Charles R. Underwood Inc
2.Well Construction Permit#:
WS0601466
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

12/22/2022 11 R 500
(gallons per minute)"
5.Well Location
Facility/Owner Name*
J.D.Carmichael, Inc. Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Scotland 01024401010
Physical Address* Street Address
20227 Old Maxton Road
Address Line 2
City State/Province/Region
Maxton NC
Postal/Zip Code Country
28364 US
Latitude* 34.4302630000 Longitude*-79.2344800000
Decimal degrees Decimal degrees
........ ................ ......... ........................... ........................... ......... ......... ......... ...................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
172 surface?
For multiple wells list all depths if different 172
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
21 17
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
500 13a. Method of test:
If applicable Pump
13b. Disinfection type:* 13b.Amount:
HTH 1 lb

14.WATER BEARING/FRACTURE ZONES
From To Description
62 97
in feet in feet
124 135
in feet in feet
141 167
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
77.00 97.00 8.00 SCH 40 STAINLESS
in feet in feet in inches
125.00 135.00 8.00 SCH 40 STAINLESS
in feet in feet in inches
142.00 167.00 8.00 SCH 40 STAINLESS
in feet in feet in inches
18.GROUT
......................
From To Material Emplacment Method&Amount
3.00 60.00 Bentonite Grout Tremie/Pump
in feet in feet
0.00 3.00 Neat Cement Pour
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
60.00 172.00 #3 Well Gravel Tremie
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
in feet in feet
21. Remarks
.......................................................................................

0'—1'Black Top Soil
1'—5'Sandy Clay,Tan
5'—7'Clay, Light Grey
7'—17'Sand,Coarse,White
17'—20'Clay,White
20'—21'Clay, Orange
21'—27'Sandy Clay
27'—37'Clay with fine sand lenses
37'—42'Sand,White
42'—56'Sand,Coarse
56'—62'Clay,Tan
62'—97'Sand,Chatter,Jet
97'—124'Clay, Light Grey
124'—135'Sand,few fine clay lenses,chatter
135'—141'Clay
141'—167'Sand,chatter,jet
167'—181'Clay, little sand mix
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
..................................................................................................................................................
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification ,
Apal L",
Signature of Certified Well Contractor