GW1--00920_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD (GW-1) For Internal USe Only: ,I
1.Well Contractor Information: •
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Frankie L.Oliver I L14.1WATER:ZONES rp., r, n^ _, .°.�, r ,,,. -i"4,
Well Contractor Name i FROM TO ' DESCRIPTION
165 _ ft* 230 ft' 1 1
3002-A
245 ft- 268 ft' 280 1 ,
NC Well Contractor Certification Number I rlSIOUTERCASING-(riot sold:ethi`clAyelis)'.OR:LINER(if'itp-Hcabfe)' 4i,
Carolina Well Drilling ` FROM TO '! DIAMETER ' THICKNESS MATERIAL
Company Name 1
0 ft. f.' 10 i h;' SDR21 PVC
',16":1NNER CASING OR'.TUBING(}(issttltertiial elosed loop)iw,.i'_ "I`s, '. ,t".',.:
2.Well Construction Permit#: N/A i FROM 'TO ; DIAMETER ' THICKNESS MATERIAL
List all applicable well construction pennies(i.e.UWC,County,State,Variance,etc.) 0 fa 152 ft 6`1/4 In SDR21 PVC
3.Well Use(check well use): , it. ft, to
Water Supply Well: I ;.17:iSCREEN °A;j0 r:r,1 .',+k ��j, r?'f5 .:. wJI.j. ,.:
FROM TO i DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I DMunicipal/Publlc tt, ; it, '! in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. n, i in
Industrial/Commercial Residential Water Supply(shared) r411;GItOU ,T er,r{R;,r ' it:.,' : " ", ..;ey s N ' - -u :s.
Irrigation FROM TO • i • MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 0 ftl 20+. ft- Bentoniite Pour(26)50Ib Bags(6")
Monitoring i DRecovery 0 fL 20+ ft. . Bentonite Pour(14)501b Bags(10")
Injection Well: rt. rt. , ,
Aquifer Recharge EDGroundwater Remediation
4 1'9.'SAND/GRAVEL,PACl (irappllcable)t jv: ). :,j4ii. fjjj,°.r4, it,,. ` :�',.
Aquifer Storage and Recovery 1 oSalinity Barrier FROM TO' MATERIAL EMPLACEMENT METHOD
Aquifer Test 1 E3S to nu w at er Drainage rt. it- '
Experimental Technology i OSubsidence Control it ft. '
Geothermal(Closed Loop) i DTracer ti{-201`DRILL:LNG'Ist)G_(8ttiich'ad ditlerial'stieetS lithe cessary)`.,'. ._ra:t,•.. ..r+.. r
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,seltlmck type,groin size,etc.)
i 0 ft• 12 fL Brown Sand
4.Date Well(s)Completed: 1-16-24 WellID# 12 ft- 40 ft' Brown1Sandclay
'5a.Well Location: 40 ft' 65 ft. White Clay
Anh Le Cason Farm LLC Well#2 65 rt• 122 ft- Brown'Sandclay„_, ,-_. ,,,--,re—
a\
.Facility/Owner Name i Facility ID#(If applicable) 122i'L 140 Grey Clay •x--
3011 Cason Oldfield Rd. Mo(:VEN 28)19 140 ft- 300 ft. Granite !-tl3 ® R ZOZ4
IL IL
Physical Address,City,and Zip
N/A 21:sREMARKS,jjii`"._..,..�V 40f:ii , ..ti; Rr' :f FfVjt,, ,*
Anson OW
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.49.931 N' 80.40.755 W 1-22-24
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6.Is(arc)the well(s) Permanent or E3Temporary 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: IJYes or j f'No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Sttitular&and that a
If this is a repair,fill out known irell construction irtformation and explain the nature of the copy of this record has been provided to the well owner.
repair under int remarks section or on the back ofthis form. 23.Site diagram or additional we►l,details:
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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 details. You may also attach additional pages if necessary.
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells
'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®l00') construction to the tollowing:
10.Static water level below top otjcasing: 32 (rt) Division or Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1 11617 Mail Service Center,Raleigh,NC 27 69 9-1 61 7
11.Borehole diameter: 16 (in.) 24b.For Injection Wells:.In addition to sending the form to the address in 24a
i 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 -
l Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS]ONLY: - 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 25 1 Method of test: Air . ' 24c.For Water Supply&Tnjcctidn Wells: in addition to sending the form to
I the address(cs)`above, also inbmit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 1802 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 Revised 2-22-2016