GW1-2021-00821_Well Construction - GW1_20210215

This form can be used for single or multiple wells
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
PROM TO DESCRIPTION
Well Contractor Name 290 ft 325 rL 10GPM
4449A IL I ft
NC Well Contractor Certification Number IS OUTER CASING form•Itit•sed wells)OR LINER B• ble
Rowan Well Drilling PROM TO DIAMETER TRICKNEss NAl"F.RIAI.
9 0 ft 45 ft 6114 in. I SDR21 PVC
Company Name 16.INNER CASING OR TUBING tothermal closed-too
AP307362 PROM TO DLIMETER THI('RNESS MATERIAL
2.Well Construction Permit#: ft I It. is
Llsl all applimble well pennies(i.e.Cosroy,Slate, Variance,Injection,eic)
ft I ft to.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DIAMETER SLOT 52E TtlICKNGsS MATEMI,
fl. ft n
OAgricultllfal OMunicipaVPublic
DGeothermal(Heating/Cooling Supply) EAesidential Water Supply(single) ft. fL 1O'
❑IndusniaVCommercial OResidential Water Supply(shared) I3 GROUT
PROM 10 MATERIAL EMPWCEMENT METHOD&AMOUNT
DIrrigaition 0 fl. ft Holeplug Gravity 8 bags
Non-Water Supply Well: R tr
OMonitoring ORecovery
Injection Well: ft ft
OAquifer Recharge CiG oundwater Remediation 19.SAND/GRAVEL PACK • bk
MATERIAL EaR1ACRMP.NT METHOD
OAquifa Storage and Recovery O FROM Salinity Barrier fL 7'O ft
OAquifer Test OStorrnwater Drainage ft ft
ClExperimenml Technology OSubsidence Control
20.DRILLING LOG farach additional sheens if necessary)
OGeothermal(Closed Loop) OTracer mom TO DESCRIPTION color bards raNr°ck qt,grain she,do
OCh thermal (Heating/Cooling Return OOther(explain under#21 Remarks 0 R. 18 ft Red Clay
1/14/21 AP307362 18 R. 35 ft Sandy overburden
4.Date Well(s)Completed: Well ID# 35 & 45 ft Solid Rods
5a.Well Location: fl. Is.
Northlake Developers
It. ft
Facikty/Owner Name Facility ID#(if applicable) ft. ft
378 Kenway Lp, Mooresville 28117
IL ft
Physical Address,City,and Zip 21.REMARKS
Iredell 4639311134
Canty Parcel Identification No.(PIN)
Latitude and Longitude in degrees/minutes/seconds or decimal degrees: y2-Certification:
(if(if N
well field,one Iaong is sufficient)
35 38 2.706 N 80 54 29.247
Sigmtr°e of Certified well Contractor Dare
6.Is(are)the weB(s): ®Permanent or CITtmpoary By signing this farm,I hereby,certify shoe the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or ENO ropy ofthu record hos been provded ro the wef/owner.
If this a a repair,fill out brown well Canurucrion information anderplom the rmmre of the
repoir ceder#21 remaris section or on the back ofthn form. 23.Site diagram or additional well derails:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Formuluple oyeetion or non-water supply wells ONLYwdh lhesmarcoaswcdon,you can -
- SUBMITTAL RVSTUCTIONS
snbnn one form. 325
9.Total well depth below land surface: _ (fL) 24a. For AN Wells: Submit this form within 30 days of completion of well
For multiple we(Lr list aft depths Jdi$erem(¢sample-3®100'and1Q100') 5 a 202foustmction to the following:
10.Static water level below r tUt 1 Division of Water Resources,Information Processing Unit,
top of causing: (ft) nE
!f weer tenet is above caring,we 1617 Mail Service Center,Raleigh,NC 27699-1617
);. , ..
11.Borehole diameter: 6 � 246. For tniectioD Wells ONLY: In addition to sending the form to the address N
otary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: constructions to the following:
(i.e.anger,rotary,cable,dues push,M.)
DIVi81an of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yids(gpm) 10 Memos Airlift 24c.For Water Supply&Injection Wells:
hlorine 14 oZ Also submit one copy of this form h thin 30 days of completion hof
e
13b.Disiall"don type: Amount: well cucted. ton to the county haler department of the county where
constructed.