GW1--07961_Well Construction - GW1_20231208

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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 132 ft- 139 ft-
et. et.
NC Well Contractor Certification Number 15.13UTER CASING(for multi-cased wells)OR LINER(if applicable) `
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft" 45 ft" 61/4 in' SDR21 PVC
Company Name
.16.INNER CASING''OR TUBING'(geothermal closed-loop)•';.'
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit's(i.e.UIC,County,State,Variance,etc.) ft. rt. in.
3.Well Use(check well use): ft ft. in.
•17.SCREEN ', .,;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT ' - "' .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 EL 20+ ft" Bentonite Pour(14)50Ib Bags
Monitoring DRecovery ft. ft.
Injection Well:
F[. f[.
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK(irappticable) ,,„
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test lStormwater Drainage ft. ft.
Experimental Technology OSubsidence 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,suil/rock type,grain size,ere.)
0 ft. 24 ft- Orange Sandclay
4.Date Well(s)Completed: 10-18-23 Well ID# Well#4 24 ft- 300 ft. Granite
5a.Well Location: ft ft ,.—1----, w:--•F'=,?S"
Lucky Family Farm ft. ft. t• ,r.L-i L.,( '/ .1...a
Y Y ( PP ) rt. rt. DEC 0 8 21)2 3
Facilit /Owner Name Facilit ID# if a licable
5888 Hwy.742 South Wadesboro 28170 ft. Ft.
It h.,nrs ...�:1 Pr!".'-'-'`.:- ." ,
Physical Address,City,and Zip ft ft Dt`v is�0G
21.REMARKS, '
Anson N/A
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:
34.88.327 N 80.09.543 w,
11-3-23
6.Is(are)the well(s)EaPennanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby cen(fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or >INo with 15A 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 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@200'and 2@100') construction to the following: '
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10.Static water level below top of casing: 17 (ft.) Division of Water Resources;Information Processing Unit,
Twiner level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27 699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In additionl to sending the farm 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
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 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: 18o2 completion of well construction Itol 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