GW1--00929_Well Construction - GW1_20240209

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION '
3002-A 70 ft- 216 ft-
233 ft. 355 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
0 ft. 65 rt. 6 1/4 I in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-Ioop) ,-. '
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.INC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'NI Residential Water Supply(single) ft, ft. in
Industrial/Commercial QIResidential Water Supply(shared) -18.GROUT :1 ' .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ fL Bentonite , Pour(14)50Ib Bags
Monitoring DRecovety ft. fL
Injection Well: •
ft. rt.
Aquifer Recharge 0 Groundwater Retnediation
IS.SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery EllSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStomtwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. n-
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) __ _ -
Geothermal FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft' 8 f`' Orange Sandclay
4.Date Well(s)Completed: 12-29-23 Well ID# 8 it 40 ft' Brown'Sandclav
5a.Well Location: 40 ft' 57 ft' Grey Clay
VPTP Poultry LLC Deep Creek Farm Well#1 57 it 400 ft Granite ; "' . ».
Facility/Owner Name Facility ID#(if applicable) It. ft
Deep Creek Rd.Wadesboro 28170 ft. ft. �-tij 9 9 1024
- Physical Address,City,and Zip rt ft. •. , 7rt^�9 iF2��
Anson N/A , 21.REMARKS .. t,r,;;, �^,`._..tail-SOA
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: •
•
34.50.907 N 80.70.069 W
1-22-24
6.Is(are)the well(s)EaPerinanent or 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: [jYes or Eallo 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. 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:
10.Static water level below top of casing: 20 (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 additionl 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 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