GW1-2021-01723_Well Construction - GW1_20210323

1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FlIOM T DESCRIPTION
Well Contractor Name
4449A R. R.
R. A.
NC Well Contactor Cenificalion Numher 15.OUTER CASING for malti-used welh OA LINER if a hk
Rowan Well Drilling FROM TO DIAMETER TTIICKNFSS MATERW.
R. I IJU t4 Jib 1/4in.
Company Name 309023
IG INNER CASING OR TUBING eoMermal CIOICKNFo
2.Well Construction Permit#: FaoM To DIAMETER 7HICKNFS3 MATERIAL
List all applicable well co,utmetion permits p.e.(11C,C'ounly,State.Variance,eta.) fL tL in.
3.Well Use(check well use): A. D. to
Water Su Well: 17.SCREEN
PPIY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public R. tl. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) n• D, io.
❑lndusbial/Commercial OResidential Water Supply(shared) I&GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATEmAL MPIACENIV ETHODk AMOUNT
Noe-Water Supply Well: N: rt o ep ug ravl ags
OMonitoring ORecovery ft H.
Injection Well: ft. I ft.
OAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK ifa iuble
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMEh'T'METHOD
OAquifer Test ❑Stonnwater Drainage R• R•
❑Experimental Technology OSubsidence Control 0. ft•
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheen if is eeasa
OGeothermal Heatin Conlin Return) OOther(explain under#21 Remarks mom To Esaurrlon color h..da ,v;urwxa
2/9/2021 309023 ft. 20 It ay
4.Date Well(s)Completed: Well ID# R• a 5andy Uverburden
rt. R. 0 1 OC
5a.Well Location: 79—
Rommel Santos ft. rL
FacOity/Owmer Name Facility ID#(if applicable) ft, R.
124 Clark Branch Ln, Mooresville 28115 ft. rt.
Physical Address,City,and Zip ft. ft. V
Iredell 4658 82 8689 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/scconds or decimal degrees:
(if well field,one laulong is sufficient) 22.Certification:
35 36 43.833 N 80 49 15.640 w
6.Is(are)the well(s): OPermaoeat or OTemporary Signature of Certified Well Contactor Date
Ny signing this farm,!hereby certify shot the well(s)cam(were)constructed m na tindanee with
7.Is this a repair to an existing well: OYes or Main 15A NC'AC 02C 0100 or 15A NCAC 02C 0200 Well Cunt-t aion,Standards and that a copy
/fthdr is a repay.fill our krrown well constriic'linn mformanou and explain the nature of the ofthis record has beenprovided to the well owner
repair under121 remarks.section or an the back of this form.
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 ConsWction info
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled. I 405 24.SUBMITTAL INSTRUCTIONS
9.*total well depth below land surface: (ft.) Submit this GW-I within 30 days of well completion per the following:
p'nr mnlaple wells list all depths ifdif(erent(example-3@200'and 2C100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 2 7 699-1 61 7
ifwnter level is rah iv,casing,use
6 24b. For Infection Wells:Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter: Rotary (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su 1 and O n-Lon Geothermal Return Wells:Copy to the
(i e.auger,rotary,cable,direct push,etc.) county environments a department o e county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodggin over 100 000 GPD:Copy to DWR,CCPCUA
3.5 Airlift Pe nrt Program, 1611 MSC,R el , C 2 699-1611
13a.Yield(gpm) Method of test:
Chlorine 16 oz
13b.Disinfection type: Amount: