GW1--00923_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONE5
FROM TO DESCRIPTION
Well Contractor Name
3002-A 72 ft" 250 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)`OR'LINER(if applicable) :
Carolina Well Drilling FROM TO DIAMETER ' THICKNESS MATERIAL
Company Name 0 fL 57 ft. 61/4!• in' SDR21 PVC
16.INNER CASING OR TUBING(geothermal 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.) fL ft. in.
3.Well Use(check well use): ft ft in.
17.SCREEN .• F,- . .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in.
Industrial/Commercial DResidential Water Supply(shared) ttt'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 20+ fL Bentonite Pour(10)50Ib Bags
Monitoring DRecovery ft. ft.
Injection Well:
et. ft.
Aquifer Recharge 0Groundwater Remediation
- 19.SAND/GRAVEL PACK(if applicable) " _ •
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage' rt. it.
Experimental Technology Oi Subsidence Control ft. fL
Geothermal(Closed Loop) (Tracer 20.DRILLING LOG-(attach additional sheets if necessary) ' `
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilirock type,grain size,etc.)
0 f` 6 fL Brown Sand
4.Date Well(s)Completed: 12-22-23 Well ID# 6 ft' 16 IL White Sandclay
5a.Well Location: 16 f` 26 ft- Orange Sandclay
Vanessa Tran Well#4 26 rt. 45 f` Grey,;Clay
Facility/Owner Name Facility ID#(if applicable) 45 ft- 300 ft" Granite '�/ �;
Teal Hall Rd.Morven 28119 ft. ft. LL vv 5..
Physical Address,City,and Zip it. ft. LF ?'oL4
Anson N/A 2t.REMARKS., i ,-
I:c tniarnla tql PicvmmungUrits
County Parcel Identification No.(PIN) ('Ah{lWaCU3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.52.526 N 80.40.649 W
Cj 1-12-24
6.Is(are)the well(s)EiPerinanent or 01 Temporary Signature of Certified Well Contractor i 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 ONo with ISA NCAC 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 under#21 remarks section or on the back of this form. I
23.Site diagram or additional well details:
S.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 .411 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a�200'and 2®100) construction to the following: 1
10.Static water level below top of casing: 28 (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 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.)
Division of Water Resources,fUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 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: 1802 completion of well construction Lo the county health department of the county
where constructed.
Form GW-1 North Carolina Department at'Environmental Quality-Division of Water Resources Revised 2-22-2016