GW1-2021-01699_Well Construction - GW1_20210215

This form can be wed for single or multiple wells I I
I.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 180 ft. 225 ft. 1 GPM
4449A 365 ft. 405 ft. ` 3 GPM
NC Wall Contractor Certification Number IS-OUTER CASING for multi cased wells`OR LINER ifs licabte
FROM I TO DIAMETER THICKNESS I MATERIAL
Rowan Well Drilling 0 ft. 180 ft. 6 1/4' in. SDR21 PVC
16.INNER CASING:OR TUBING'fiteothermal closed-loo
Co pasy Name 334919 FROM I TO I DIAMETER TH[C"ESS MATERL41,
2.*Fell Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. in
3.Well Use(check well use): 17.SCREEN
Wa ter Supply Well: FROM TO I DIAMETER I SLOTSiEL I THICKNESS I MATERIAL
in.
❑Agricultural OMunicipaUPublic ft. ft. '
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(Single) ft' ft. is
❑l dustriaUCommercial OResidential Water Supply(shared) Is*GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]litigation 0 ft. 20 ft. Holepiug Gravity 50 bags
Noh-Water Supply Well: ft. &
OMonitoring ❑Recovery
Injl ction Well: ft' ft'
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery OSalinity Barrier ft. fL
❑Aquifer Test OStormwater Drainage ft. %
OP,xperimental Technology OSubsidence Control 20:DRtLLING LOG attach additional sbeets if necessary)
O6eothermal(Closed Loop) OTracer FROM To DESCRIYTTOx .rotor,hardnes,soiuroek etc
❑geothermal(Heating/PoolingReturn ❑Other(explain under#21 Remarks 0 ft 18 ft. Clay
1/22/21 334919 18 & 120 ft. Sandy Overburden
4.Date Well(s)Completed: Well ID# 120 IL 170 ft. Weathered Rock
Say.Well Location: 170 ft. 180 ft. Solid Rock
Aaron Jones 190 ft. 265 ft. Bridle brown rock
Facility/Owner Name Facility lD#(if applicable) ft. ft
6071 W NC 152 HWY, Mooresville 28115
ft. ft.
Ph peal Address,City,and Zip 234029 21`REARKS
K M
owan
County Parcel Identification No.(PIN)
5bl,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well fietd,one Wong is sufficient)
35 34 37.292 N 80 421.989 PA,
jl— ! ltZ)
sf"
vrd°r '^Sigoa of Certified Well Contractor Date
6.Ys(are)the weil(s): @Permanent or OTemporary ing this form,I hereby certify that the well(s)was(were)constructed in accordance
r to 1 0 10A NCAC 02C.0100 or JSA NCAC 02C.0200 Well Construction Standards and that a
7.7s this a repair to an existing well: OYes or E)No ` copy pft he,Ord has been provided to the well owner_
If this is a repair,fill out known well constmciton information and explain the nature of the- rAt` '
al well details:
repair under 42J remarks section or on the back of thisform. `j;j-Q01 ,': a ti�, r^ may use the back of this page to provide additional well site details or well
8.Number of wells constructed: ffi
1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form. 405
9.Total well depth below land surface: (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,Ilse"+-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of,this form within 30 days of completion of wei
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 WELDS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3.5 Airlift 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
Chlorine 17 oZ well construction to the county'health department of the county where
IJb.Disinfection type: Amount: constructed.
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