GW1-2021-01724_Well Construction - GW1_20210323

1.Well Contractor Information:
Spencer Adams M WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 305 It. 2 GPM
4449A tt• 425 n• 2 GPM
NC Well Contractor Certification Number I&OUTER CASING for molti�ed Welk OR LINER Ra 6k
Rowan Well Drilling FROM TO DIAMETER THICKNESa MATERIAL
0 rt. 4 n• 6 1/4 in. SDR21 PVC
Company Name 311085 JMB2209 16.INNER CASING OR TUBING anal closed-too
2.Well Construction Permit#': mom TO DIAMETER THICKNESS MATERIAL
Lit all applicable well con truclion permits fix.UIC,Court State.Variance.etc.) n, It. in'
3.Well Use(check well use): ft. n. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(l leating/Cooling Supply) EOResidential Water Supply(single) n• n. io,
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
-Irrigation FROM 1 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n n• EZSeaI Pump 25
Monitoring 13Recovery ft. n.
Injection Well:
Aquifer Recharge OGroundwater Remediation
If.SAND/GRAVEL PA Iif
Aquifer Storage and Recovery OSalinity Barrier mom TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. n.
Geothermal(Closed Loop) OTmcer 21.DRILLING LOG Iattach additional sheets If
Geothermal(Heatin Conlin Return) nOther(explain under#21 Remarks) FRoM TO 01S 111PTION J color,him].miVoekt sma,dr.
In. n. a ay
4.Date Well(s)Completed: 2/17/21 Well IDr 311085 tt. 25 n• Sandy Overburden
5a.Well Location: 25 tt ___45 n• Solid Rock
Dane & Jennifer Baltic tt. «•
FaciinylOwoc Name Facility LD#(if applicable) ft. n.
266 Lakeview Shores Loop, Mooresville 28117 n. n. 21
Physical Address,City,and Zip ft. ft.
Iredell 4627214847 21.REMARKS
Count, Parcel Identification No.(PIN) Ell
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
35 34 49.964 80 56 33.273
N W �titi—� �✓�_ �� C�� � 2
6.1s(are)the welbs)Ot Permaneol or OTernporary Signature of Certified Well Contractor Date
By signing this form.T herebv cernA that the w,116) was(were)constructed in u cardnnce
7.Is this a repair to an existing well: OYes or ©No with 15A NCAC 02C,0100 or 15A NCAC 02C.07W Well Construction Standards and that a
If this is a repair,fill ont known well coaoruclion information and a cphin the nature of the copy of this record has been provided to the well owner,
repair under#21 remarks section or on the buck of this form_
23.Site diagram or additional well details:
8.For Geoprobe/UPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constructon,only I G W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I 425 SUBMITTAL INSTRUCPIONS
9.Total well depth below land surface: (DJ 24a, For All Welk: Submit this form within 30 days of completion of well
For multiple wells lit all depthr if digerem(example-3@200'andl@100') construction to the following.
10.Static water level below top of rasing: (flJ Division of Water Resources,Information Processing Unit,
If comer level is above casing,use ,. ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the forth to the address in 24a
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 c.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 27699-16M
13a.Yield(gpm 4 Method of test: Airlift 24c.For Water Supply& Infection Wells: In addition to sending the forth to
Chlorine 18 OZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.