GW1-2021-03167_Well Construction - GW1_20210625

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Friars Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams A&WATERZON>ys A FROM TO DESCRIPTION k
Well Contactor Name 265 fL 285 19 GPM
4449A
ft. ft.
NC Well Contractor Certification Number S.OUTER CASING'for muhi-cased wens OR LINER I-ble
Rowan Well Drilling FROM To DIAMETER THICKNESSI MATERIAL
Company Name 0 ft 80 ft 61/4 in SDR21 JPVC
3�)CO�Q I&INNERCASINGORTUBING eethermalelosed400
2.Well Construction Permit#: 1 V d FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State Variance eta) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17tSCREENFROML TO I DIAMETER I SLOT SUZ I THICKNESS MATERIAL-
Agricultural [3Municipal/Public 0 ft. ft. in
Geothermal(Heating/Cooling Supply) Olkesidential Water Supply(single) it.
ft-
industrial/Commercial DResidential Water Supply(shared)
l8.GROUT:­
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Holeplug Gravity 22 bags
Monitoring E31tecovery ft. "ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19:SANDIGRAVELPACK Bcable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL. I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 0Snbsidence Control (L fL
Geothermal(Closed Loop) ElTracer 20:DRILLING LOG stench additionat sheets fi necess
Geothermal(Hcatingfpooling Return Other lain under#21 Remarks FROM TO DESCRIPTION color,issifte4 soNroek ope,grain size,eta
0 rt. 30 ft- SandylClay'
4.Date Well(s)Completed:5�14/21 well ID#316039 30 ft• 70 L ' Weathered Rock
Sa.Well Location: 70 ft- 80 ft- Solid Rock
Randy Hollifield ft. ft
Facility/Ownerhame FacilityID#(ifapplicable) ft' ft'
VW%L--.W I —d'
198 Shoreline Loop, Mooresville 28117 ft. ft 5
Physical Address,City,and Zip ft fL 1.a of
Iredell 4635570819 21.REMARKS }'
tla.. -DVJR
County Parcel Identification No.(PIN)
F-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 32 34.387 N 80 53 56.185 W S--(/-( 12
6.Is(are)the well(s)E)Permanent or Temporary Signature of Certffied Well Contractor, Date
By signing this form.I hereby certify'that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: OYes or ElNo with ISA NCAC 02C.01W or ISA NCAC 02C.0200 Well Construction Standards and that o
Ifthis is a repair,fill aid known well construction information and explain the nature of the copy of this record has been provided fo the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
g.For Geoprobe/DPT 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface: 305 O 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Different(example-9@200'and 2@100) construction to the following:
I
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
Ifwater level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 24b.For Injection Wells: In addition to sending the form 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.e,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 27699-1636
13a.Yield(gpm) '9 Method of test:Weir 24c.For Water Supply&Injection Webs: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:Chlorine Amount: 14 oz completion of well construction'to the county health department of the county
where contracted. fj
Form GW-1 North Carolina Department of Emrironmental Quality-Division of Water Resources Revised 2-22-2016