GW1-2021-04480_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD G _ For Internal Use Only:
1.Well Contractor Information: �r
Spencer Adams {' �� �>;5��� 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
�` �Q �� 125 ft- 145 n• 5 GPM 1
4449A 3�`°y,1� 255 n• 285 n- 14 GPM
NC Well Contractor Certification Number \e�tJ��, 0 j 15 OUTER CASING for mold�ased wells OR LINER f applicable)
FROM To DIAMETER TMCKNESS MATERIAL
Rowan Well Drilling
0 ft 102 fL 6 1/4 !" SDR 21 JPVC
Company Name 331536
16.INNER CA31NG OR TUBING eotherrnai closed-too
2.Well Construction Permit#: f FROM I TO DIAMETER 71HCKNESS MATERIAL
List all applicable well construction permits#e.WC,Count};Stag Variance,etc.)1 fL fL to
3.Well Use(check well use): fL ft. in
Water Supply Well; 17.FROM SCREEN.TO I DIAMETER I SLOTSIZE I 7MCKNFM I MATERIAL
Agricultural QMunicipal/Pnblic 0 fL It.
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. fL In.
Industrial/Commercial Residential Water Supply(s7tared) It GROUT
LTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Holeplug Gravity 21 Bags
Monitoring Recovery ft. ft.
Injection Well: it ft.
Aquifer Recharge E)Groundwater Remediation
19.SAND/GRAVEL PACK f applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETROD
Aquifer Test QStonnwater Drainage n• M
( Experimental Technology OSubsidence Control f 1 n• n•
Geothermal(Closed Loop) QTracer 1 20.DRILLING LOG attaeh additional sheets if necessary)
Geothermal eatin Cooli Retum Other lain under#21 arks FROM 7O nFscRtPTtox rotor aoiVroek eta
0 rL 20 n• Clay l ',
4.Date Well(s)Completed:3/23/21 Well 331536 # 20 rt 80 fL Sand Overburden
5a.Well Location: ( 80 ft• 92 fL Weathered Rock
Chad Ulrich 92 fL 102 n• Solid Rock
Facility/Owner Name Facility ID#(ifapplicable)i ft ft
475 Cal Kennedy Rd, Cleveland n. L F
Physical Address,City,and Zip E ft, fL
Rowan 277 057 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. ertification:
35 43 36.686 N 80 43 8.175
6.is(are)the welf(s)OPermanent or Temporary
Signature of Certified Well Contractor Date
By signing this form,1 hereby—ify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or []No I with 1SA NCAC 02C.0100 or ISA MC4C01C.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 ofthis record has been provided to the well owner.
repair under#11 remarks section or on the back of this form. i
} 23.Site diagram or additional well details:
! You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the aspic construction details:You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wel
drilled:It SUBMri-fAL INSTRUCTIONS
9.Total well depth below land surface:285 1 (ff) 24a.For Ati Wells:Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfakfferent(example-3Qa 200 and 2Qo 100) i construction to the following:
10.Static water level below top of casing: ((L) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" { 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter- (in.) f 24b.For Iuiection Wells: In addition"to sending the form to the address in 24a
Rotary { above,also submit one copy of thi I form within 30 days of completion of well
12.Well construction method: construction to the following:
(i,c.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
139.Yield(gpm) 19 Method of test:weir ! 24c.For Water Supply&Inlecti-gp Wells: In addition to sending the form to
the addmss(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:Chlodne Amount: 12 OZ completion of well construction to'ithe county health department of the county
where constructed.
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Form C,W_t North Carolina Depasunent o4nvironmental Quality-Division of Water Resources li Revised 2-22-2016
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