GW1--00922_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES° - • i - - _ . ' .
FROM TO DESCRIPTION
Well Contractor Name
110 ft. 153 ft'
3002-A 268 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING`(for multi=casedrwells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 43 ft. 61/4! 'n' SDR21 PVC
Company Name 16.INNER CASING:OR TUBING(geothertital closed-loop);,•
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. in.
3.Well Use(check well use): ft ft I in.
17:'SCREEN'
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. iu:'
Geothermal(Heating/Cooling Supply') °Residential Water Supply(single) ft. it. in.
Industrial/Commercial OResidential Water Supply(shared) .18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft" 20+ ft- Bentonite Pour(10)501b Bags
Monitoring lDIRecovety ft. ft. ,
Injection Well:
ft. ft.
Aquifer Recharge iDIGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test tStormwater Drainage et. ft.
Experimental Technology 01Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) IIOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,s°iUrock type grein size etc.)
0 ft 6 ft- Brown Sand
4.Date Well(s)Completed: 11-30-23 WellBO 6 ft' 19 ft' Orange Sandclay
5a.Well Location: 19 ft- 400 ft' Granite
Hai Le Farm#2 Well#1 It. ft.
Facility/Owner Name Facility ID#(if applicable) fG ft.
Gulledge Rd.Wadesboro 28170 ft. ft.
Physical Address,City,and Zip ft f[ •
I uu V 2024
Anson N/A 2I.REMARKS - iiw.:..:-%I.".1'P".:..:"..t...:t:)'i45
DW
County Parcel Identification No.(PIN) O/200
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.Certification: .
34.51.771 N 80.60.974 `l,
c 12-15-23
i�I Temporary
of Certified Well Contractor ! Date
6.Is(are)the well(s)ElPennanent or
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 fy aiNo with ISANCAC 02C.0100 or ISA 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 sunder#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: 400 (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@100') construction to the following: 1
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
Tfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection 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
1
13a.Yield(gpm) 30 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: 24oz 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