GW1-2021-04479_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �I j.
Spencer Adams i�� 14.WATERZONES
Vic
Well Contractor Name 0, TO DESCRIPTION
�� 15 ft- 345 ft• 70 GPM
4449A PQ� Q�ose o ft. ft.
NC Well Contractor Certification Number ���age, 15.OUTER CASING for multi-cased wells OR LINER if a licable
Rowan Well Drilling aS. �yJ FROM 7'O DIAMETER THICKNESS MATERIAL
Company Name 0 fL 88 ft. 6 1/4 in SDR 21 JPVC
2 oo 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 8 FROM TO DIAMETER THICKNESS I MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 ft. ft. in.
J Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
_I IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
_1 Geothermal
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 20 ft. Holeplug Gravity 8 bags
Monitoring Recovery
Injection Well:
ft It.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage fa ft.
Experimental TechnologySubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
_Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain siw,etc
0 fL 20 IL Clay j
4.Date Well(s)Completed:3/23/21 Well ID#278009 20 ft. 78 it, Weathered Granite
5a.Well Location: 78 fL 88 ft. Solid�Rock
Jose Diaz ft. ft.
Facility/Owner Name Facility ID#(if applicable) It. ft.
2140 3rd Creek Ch Rd, Cleveland 27013 ft. ft.
Physical Address,City,and Zip ft. It.
Rowan 260 048 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) 7Z!i
!/
35 45 39.039 N 8041 10.062 W
3 6,312�4
6.Is(are)the well(s) XI Permanent or MTemporary 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: ®Yes or 19No with 15A NCAC 01C.0100 or 15A NCAC 01C.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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a3200'and 2@100) construction to the following:
i
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water 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 fort 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) 70 Method of test:Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 15 oz completion of well construction to the coup health department of the
13b.Disinfection type: Amount: P I county P county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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