GW1-2021-04477_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams �� 14.WATER ZONES t
Well Contractor Name kd
OLX
FROM TO I DESCRIPTION
4449A w 05 ft325 rt 2 GPM
Gec'y\4 M It.
NC Well Contractor Certification Number P !) %O�
Qtc 15.OUTER CASING for multi cased wells OR LINER if a IHcable
Rowan Well Drilling S� FROM TO DIAMETER rHncKNEss MATERIAL
Company Name g �� � 0 fR 105 M 6 1/4 i° SDR 21 PVC
330099-1`� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER i SLOT SUE THICKNESS MATERIAL
Agricultural ®Municipal/Public 0 fL It. in.
XI
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL in.
IndustriaUCommercial E311csidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 a. Holeplug Gravity 18 bags
Monitoring 13Recovery fL ft.
Injection Well: fL ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK f applicable)
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. FL
Experimental Technology 13Subsidence Control ft. ft.
J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness,soWrock VjM grain dze,etc
IL 18ft. y
4.Date Well(s)Completed:3/30/21 Well ID#330099-1 18 ft- 85 ft Sand `Overburden
5a.Weil Location: 85 fL 95 IL Weathered Rock
IQ Customs 95 ft. 105 ft. Solid Rock
Facility/Owner Name Facility ID#(if applicable) ft. ft
355 Cal Kennedy Rd, Cleveland 27013 I. ft.
Physical Address,City,and Zip fL ft.
Rowan 277 051 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35 43 30.753 N 80 43 24.937 W
'5
6.Is(are)the well(s) xi Permanent or O1 Temporary Signag=of Certified 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: ®Yes or X®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form:
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pageito 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:425 (P 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) 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 (in.) 24b.For Iniection 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)2 Method of test:Airlift 24c.For Water Supply&Injection Wells: 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: 18 oZ completion of well construction to the county health department of the county
where constructed. f
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016