GW1-2021-04478_Well Construction - GW1_20210429

r._,-'Print Form___m,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams j,A 14.WATER ZONES
FRO TO DESCRIPTION
Well Contractor Name fL 405 ft 3 GPM
4449A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for mukieasea wells OR LnvER t a livable
`C �+ FROM TO DIAMETER THICKNESS MATERIAL
Rowan Well Drilling , o�` S
������ 0 ft 80 it. 6 1/4, in SDR 21 PVC
Company Name 330100 �� �` O 16.INNER CASING OR TUBING eother al closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ff• ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FR M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft ft in.
:)Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) g, ft in.
Industrial/Commercial DResidential Water Supply(shared) yS.GROUT
7)lrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 ft. Holeplug Gravity 12 bags
Monitoring ( Recovery ft. ft.
Injection Well:
IL ft.
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0Stornwater Drainage ft. ft
Experimental Technology QSubsidence Control fL ft.
Geothermal(Closed Loop) Tracer' 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther lain under#21 Remarks FROM TO DESCRIPTION color,hardo soll/mk n etc
0 n 18 ft Clay
4.Date Well(s)Completed:3/24/21 Weil ID#330100 18 ft 70 rt. Sandy Overburden
5a.Well Location: 70 tL 80 fL Solid Rock
IQ Customs ft ft.
Facility/Ow erName Facility ID#(if applicable) ft It.
470 Cal Kennedy Rd, Cleveland ft tt.
Physical Address,City,and Zip ft ft.
Rowan 277 047 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 43 31.943 N 80 43 30.387 W
3 lZ�c 12,
6.Is(are)the well(s)OPermanent or QTemporary Signature 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: OYes or 9No 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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
i
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)3 Method of test:Air Lift 24c.For Water Suggly&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: 16 oZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016