GW1--00925_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver .14:,WATER ZONES'=_ , r • ,_ i'`
' FROM TO DESCRIPTION
Well Contractor Name
70 ft. 87 ft
3002-A - 117 ft. ft.
NC Well Contractor Certification Number -15.:OUTER CASING(for multi-casedlwells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 37 ft- 10 I 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(Le.WC,County,State,Variance,etc.) 0 f4 50 fL 6 1/4 is SDR21 PVC
3.Well Use(check well use): ft ft. in.
17.SCREEN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial DResidential Water Supply(shared) tx:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 20+ f` Bentonite Pour(12)50Ib Bags(6")
Monitoring ID,Recovery 0 fG 20+ f` Bentonite Pour(9)50Ib Bags(10")
Injection Well:
ft. ft.
Aquifer Recharge iDIGroundwater Remediation (y,.SANDlGRAVEL PACK or applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (Stormater Drainage ft ft.
w
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING'LOG_(attach additional sheets if necessary) ,,
FROM TO DESCRIPTION(color,hardness,suil/ruck type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 f` 7 f` Brown Sand
4.Date Well(s)Completed: 12-19-23 Well ID# 7 f` 15 f` Red Sandclay
5a.Well Location: 15 f` 28 ft' Orange Sandclav
Vanessa Tran Well#3 28 f` 38• f` Grey Clay r-5 7 r-,., , ,/'
Facility/Owner Name Facility lD#(if applicable) 38 ft' 400 ft' Granite r, ti. L,i_c�{f t
Teal Hall Rd.Morven 28119 et. ft
I-U3 0 9 2024
Physical Address,City,and Zip ft. ft.
Anson N/A 2l.11EMARKS t,.` . e1nb tr654.4;;7 14.r0C. 6t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.52.567 N 80.40.643 W ' 1
1-12-24
6.Is(are)the wcll(s)EtPennanent or OI Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )diNo with 15ANCAC 02C.0100 or 15ANCA'C 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.
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(41100') !
construction to the following:
10.Static water level below top of casing: 17 (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
(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 27699-1636
13a.Yield(gpm) 20 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016