GW1-2021-01722_Well Construction - GW1_20210323

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name rnoM I TD DescalwnoN
4449A 136 R- 365 ft 3.5 GPM
IL I,NC Well Contractor Certification Number
M OUTER CASING f ald-cased wells OR LINER B'PIS
k
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name r'� 0 f4 136 " 61/4 in. SDR21 PVC
3 3LOO If.INNER CASING OR TUM
2.Well Construction Permit I1: FROM TO SS MATERIALLut all applicable"ell camtroetion permits(i.e.U/C,County,State. Variance,an) R ft.3.Well Use(check well use): R RWater Supply Well: 17.SCREENFROM TO DITHICKNESS MATERIAL
Agricultural DMunicipaVPublic 0 fL Geothermal(Heating/Ccoling Supply) QResidcntial Water Supply(single) n,
Industrial/Commercial 01tesidatitial Water Supply(shared) 70.CROUT
"llnigation FROM TO MATERIAL EMPI.ACEMEN'TMET1110, OUNT
Non-Water Supply Well: 0 R 20 fl- Hole lu Gravity
Mossitorin Recovery R. R
Injection Weil:
A uifer Rechar a ft R
q 8 QGroundwater Remediation
19.SAND/GRAVEL PACK applicable)
Aquifer StorTest and Recovery OStomw ter Dr FROM TO MATERIAL. EMPLACEMLYTMETHDo
� Aquifer Test �Stormwater Drainage R R
Experimental Technology OSubsidence Cannot R R
Geothermal(Closed Loop) QTmcer 20.DRILLING LOG attach additional sheets If ascertain)
Geothermal(HeatiD Co01in Return) Other(explain under N21 Remarks mom TO DEuxtmoN mbr k. saWmck alrq ac
2/24/21 313200 0 ry 20 H• Clay
4.Date Wells Com tared: W 1 n.O p e11DD 20 t20
Sandy Overburden
5a.Well Location: 120 1L 126 ft Weathered Granite
JC Development ft. fL
Facility/Owner Name Facility W#(ifapplicabk) R R _
225 Hermance Ln, Mooresville 28117
Physical Address,City,and Zip ft. ft. i,(�I I
Iredell 4638013852 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latmde and longitude in degreevesinutesiseconds or decimal degrees:
(if well field,one tattling is sufficient)
35 36 29.86 N 80 54 59.540 W 22.Certification:
6.Islam)the well(s)M% Permanent or DTemporary Signature of Certified Weil Contractor Data
Sv signing this form.1 hereby certify that the"elits)war(tsrre)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo ,vilk 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Comos crion Standards and that a
Ifthir is a repair,fill out known well com0uc ion information and explain the nature ofthe copy of this retard has been provided in the"ell owner.
repair under h21 remurks seeden or can the back ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPf 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-I is needed. Indicate TOTAL NUMBER of wells comtruction details. You my also attach additional pages if necessary.
drilled:1
SUBMITTAL INSTRUCTIONS
9.Total well depth below load surface: 365 (D-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple"el/r tut all depths ifdiJferent(erample-3@200'and 2(a)1003 construction to the following:
10.Static water level below rap of casing: ((L
Division of Water Resources,Information Processing Unit,
Ij"nre.level is slave curing.use"t" 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
12.Well con
Rota above, also submit one copy of this forth within 30 days of completion of well
(i.e.auger,rotaryry,,cable,
method: Rotary direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MaR Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 3.5 Method of teat:Airlift 24c. For Water Supply& Injection Wells: In addition to sending the farm to
Chlorine 17 OZ the address(es) above, also submit one copy of this forth Within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Cash.Department of Environmental Quality-Division of Water Resources Revised 2-22-2016