GW1--07964_Well Construction - GW1_20231208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Frankie L.Oliver atl4.WATER'ZONES " .`' ;.v tit-,' -,4
FROM TO DESCRIPTION •
Well Contractor Name 71,82 ft- 243 ft
3002-A 391 ft. 408 ft- - 1
NC Well Contractor Certification Number '-,,IS..OUTER.CASING.(for multi tased4wells).-OR LINER.(if_applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 it 62 ft' .61/4 in' SDR21 PVC
16.INNER ASING`OR`TUBING(g'eotheriiial'closed-loop), -1: z..,
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): et ft in
Water Supply Well: 4 FROM TO • DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 9Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in!
Industrial/Commercial 9IResidential Water Supply(shared) ,18.GROUT :,t 4'z... " # "
Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ ft- Bentonite Pour(15)50Ib Bags
Monitoring 19Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge i©IGroundwater Remediation
-'-I9."SAND/GRA•V.EL"PACK(if applicable)1, _
Aquifer Storage and Recovery Et Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 9IStormwater Drainage et. ft. '
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 1..20.DR:ILLING LOG`(attach•additional sheets if necessary:) , ,
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Other(explain under#21 Remarks)
0 ft. 18 ft- Orange/Red Sandclay
4.Date Weil(s)Completed: 10-6-23 Well1D# Well#1 18 ft. 23 ft. Red Clay
5a.Well Location: 23 ft- 56 ft. Grey Clay
Lucky Family Farm 56 ft. 500 ft. Granite
ft. ft- i "'.. 'r--,
Facility/Owner Name Facility 1D#(if applicable) , ("'- . ,im 1.1
5888 Hwy. 742 South Wadesboro 28170 ft.
ft. ; DEC0 8 Zn?.j
Physical Address,City,and Zip I
Anson N/A d.2i.REMARKS"- . '''', ..4 1;':';,.:':-:`:
ill il.iri,:4i..`t t r .,-3c.� �.L<iwti
County Parcel Identification No.(PIN) ID Ott3(Xi
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 ` a�
. ) 11-3-23
6.Is(are)the well(s) Perinanent or 9ITemporary 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: DYes or y!a!No with 15ANCAC 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 fa 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: 500 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depth if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Reso l rces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 on.) 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
1
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 21 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: 30oz completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016