GW1--07963_Well Construction - GW1_20231208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
.l ,
Frankie L.Oliver "114.WATER ZONES . /,.'_,. . . ,„`..
WellCantractorName FROM TO DESCRIPTION
3002-A 64,75 ft. 83,89 ft- 1
104 ft. 126 ft'
NC Well Contractor Certification Number
15.OUTER CASING(for udltt cased'wells):OR LINER(if applicable) r •
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 56 ft' 61/4 in' SDR21 PVC
Company Name ,
,.:16.'INNER CASING OR;TUBING(geothermal elased-loop);-7..- :.-_.
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. to
3.Well Use(check well use): ft ft in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OI,Municipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IndustrialCommercial OResidential Water Supply(shared) ;18.'GROUT. '' r + , `
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it' 20+ ft. Bentonite Pour(25)50Ib Bags
Monitoring 1©IRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge I©IGroundwater Remediation
N19.'SAND/GRAVEL°PACK.(if applicable)',"' ` ' ' ,
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OSCormwater Drainage
ft. ft. .
Experimental Technology OSubsidence Control ft. ft. '
Geothermal(Closed Loop) OITracer ;'20.DRILLINGLOG(attach additional sheets if necessary);.,
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
0 ft. 15 rt. Orange/Red Sandclay
4.Date Well(s)Completed: 10-10-23 Well ID# Well#2 15 ft. 50 ft' Red Clay
5a.Well Location: 50 ft- 300 ft- Granite
ft. rt. -^a '-.,.c
FT- R 7-'•F
Lucky Family Farm vk. ..L i. �.L L.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5888 Hwy.742 South Wadesboro 28170 et. ft. DEC 0 8 21:191 .
Physical Address,City,and Zip ft IL «
Anson N/A 21,REMARKS �, riZiviViir .S1 r '..1 L4:4. .-,
Ir/,e'v*.,,t t ,:›G
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: J '
34.88.327 N 80.09.543 `,l,
11-3-23
6.Is(are)the well(s)ElPermanent or 0Temporary Signature of Certified Well Contractor 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: IN Yes or !j di No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 i
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(d200'and 2Q100') construction to the following: i
I
10.Static water level below top of casing: 22 (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:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: Air 24c.For Water Supply &Injection Wells: in addition to sending the form to
the address(es) above, also snbniit 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016