GW1--00915_Well Construction - GW1_20240209

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Frankie L.Oliver 14.WATER ZONES . _, ` ''1'-
Well Contractor Name FROM- TO ' DESCRIPTION
3002-A 124 ft. 223 f`
375 ft. 555 ft.
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased`wells)OR LINEROf applicable)
Carolina Well Drilling FROM TO DIAMETER ! THICKNESS MATERIAL
0 f` 70 f` 6 1/4; in' SDR21 PVC
Company Name 16.INNER CASING''OR TUBING(geothermal eIosed.loop) 2
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS ' MATERIAL
List all applicable well construction permits(le.1.11C,County,State,Variance,etc.) ft. ft. , in
3.Well Use(check well use): ft. ft. : in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public et. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in. .
Industrial/Commercial QResidential Water Supply(shared) lg-GROUT `
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD at AMOUNT
Non-Water Supply Well: 0 f` 20+ f` Bentonite Pour(18)50Ib Bags
Monitoring IDRecovery ft. ft
Injection Well:
ft. rt.
Aquifer Recharge IDIGroundwater Remediation
19.SAND/GRAVEL PACK or applicable).' - '
Aquifer Storage and Recovery 0I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stomiwater Drainage rt. rt.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING.LOG(attach additional sheets if necessary) .,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nlOther(explain under#21 Remarks)
0 f` 6 f` Red/Brown Sandclay
4.Date Well(s)Completed: 12-11-23 Well ID# 6 f` 16 f` Red Rock/Clay
5a.Well Location: 16 ft. 45 rt. White Clay
Hai Le Farm#3 Well#3 45 rt. 60 f` Grey Clay r
Facility/Owner Name Facility ID#(if applicable) 60 IL 600 Granite F�� 2—y t ,, - ii VC
" .
Gulledge Rd.Wadesboro 28170 ft. fL
ZA
Physical Address,City,and Zip '._1
rt ft. r t� 0 5 20
Anson N/A 21.REMARKS . ' . 1f tA'�`{:D s..r,rt�}Mi 41 1�!1
County Parcel Identification No.(PIN) 02043
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.Certification:
34.51.730 N 80.70.320 `,l, c
12-15-23
6.Is(are)the well(s)EiPertnanent or Temporary Signature of Certified Well Contractor Date
By signing this fonts, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or MI No with 15A NCAC 02C.0100 or 15A NCAC 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#2 1 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: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths[fdifferent(example-3(200'and 2@I00') construction to the following:
10.Static water level below top of casing: 26 (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 additilon 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 5 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: 36oz completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016