GW1--00919_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: , ' '
1.Well Contractor Information:
Frankie L.OliverI I I"d:'WATERx7.ONESus4 r,n;c°I!'., r.aU4 .:'x ,.i ". <+ ?<
Well Contractor Name 1 FROM TO ' ' n DESCRIPTION
130 ft- 168 ft-
3002-A
209 ft. 221 ft
NC Well Contractor Certification Number
z 15�'OUTER;CASINGs(formulti eusedN velts);OR?LINEIR4if up lieable),n , ,;' 'K-:
Carolina We Drilling i FROM TO ' ' DIAMETER ', THICKNESS MATERIAL
Company Name J 0 ft. 82. ft. 61/4I in' SDR21 PVC
r:6:'INNER CASING.OR TUBING(geether"nial"elosed Loop).. w, 2? tiro a n:':
2.Well Construction Perinit#: � FROM TO , ;, _
N/A ' R THICKNESS MATERIAL DIAMETER in.Lie!all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) E- IL
3.Well Use(check well use): ft. fa !a
Water Supply Well: • NI7:SCREEN,; ,.l, : ..• : :' . 4 0. :a" ...l.1 .,, ; 's ...,'-' •:,
FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public It. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water supply(single) . to it. in.
Industrial/Commercial I Residential Water Supply(shared)
gilt'GROUT a r.t""s r:..,, 4p..e*o'3„m to .,`r.,. .-z a•a.+, , s�Qa'' .. '•4d:' '
Irrigation I FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: i 0 ft. 20+ ft. Bentonite Pour(10)50Ib Bags
• Monitoring i DRecovery et. et.
Injection Well: I "
ft. ft.
Aquifer Recharge ' DGroundwatcrRemediation
s19.'SANDIGR'AVELPACK(irapiillcable)v .t,`.,' {, t'sx b... . ,;, ;r,
Aquifer Storage and Recovery 1 ElSalinity Barrier FROM TO - MATERIAL EMPLACEAIENT METHOD
Aquifer Test I, DStotmwater DrainageIt. rt. I
Experimental Technology ` OSubsidence Control ft. It. '
Geothermal(Closed Loop) Tracer x 20MikILLING'EiOGi':(atttiehadditiodiatsLeeti'ifiteeess'tiry)ti ,.;: .-:4:= 36 ,ros4 l4it
1 FROM TO` DESCRIPTION(eeRoe,hardness,sail/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 1..110ther(explain under 4121 Remarks)
0 ft. 6, ft- Brown Clay
4.Date Well(s)Completed: 1-8-24 'Well ID# 6 ft' 14 ft. . White Clay
5a.Well Location: 14 ft' 70 ft' Brown'tandclav
Anh Le Alpha Farm Well#1 70 ft- 300 ft- Granite .
Facility/Owner Name .FacilityID#(if a licable ft. ft. ^n• f! ?
741 Deep Creek Rd.Wadesboro 28170 fA ft. I 1/4,1 '
Physical Address;City,and Zip I :ft, ft. 1 • h C3 0 9. 2O24
Anson N/A :k 21 REMARKS,�i,'t 1 .., .., at..i.',w. fi:C:: ' r? d'. i, *+s` t :"
en r tC:f.#�'
County ' ' Parcel Identification No.(PIN) , . t Gr,jQir;
513.Latitude and longitude in degrees/tninutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
34.50.474 N ' 80.60.326 W 1-12-24
6.Is(are)the well(s)aPertnanent or Temporary Signature of Certified Well Contractor , @ Date
by signing this form.I hereby certjjy thal,ahe wel(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 5allo with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standards and that a
If this is a repuir fill out known well constraCiun iufornwsion and esplaiu tie nature of she copy of this record has been provided to the well owner.
repair wider#2I 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 ifdffarent(erainple•3'200'and 2(100) construction to the following: 1
I
10.Static water level below top of casing: 29 (it-) Division,of Water,Resources;Information Processing Unit,
If water level is above casing,use"+" 1 1617 Mail Setjvlce Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6 (hi.) 24b.For Injection Wells: In additit 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: I . 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¶NLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a,Yield(gpm) 50 r Method of test- Air 24c.For Water.Supply&;Inlectioii Wells: in addition to sending the form to
I the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTti Amount. . 18oz . completion of well construction to the county health department of the county
where constructed.
Form GW-1 ' North Carolina Department ot'Environmental Quality-Division of Water Resources Revised 2-22-2016
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