GW1-2021-04636_Well Construction - GW1_20210514

rm
- .,_`�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449A tJIAy 62 It 185 It• 3 GPM
t Ui�ii
r'1rn n.;•�if� 195 fa 225 ft. 15 GPM '
NC Well Contractor Certification Numberr ;�'�f'.�
Inc,,.,r►1',36`' ,^(1011 15.OUTERCASING formulti�asedwells ORLINER ifa licable
Rowan Well Drilling }'Y,�;`•`'J J FROM TO DIAMETER TRICICNFSS MATERut,
Company Name 0 rL 62 ft. 61/4 to SDR21 JPVC
322614 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural []MunicipaMblic 0 ft ft. in.
:)Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared)
lg.GROUT
_l Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 It• Holeplug Gravity 28 bags
Monitoring _.Recovery ft. R.
Injection Well:
[L ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
J Aquifer Storage and Recovery Salinity Barrier FROM I To I MATERIAL I EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft.
C Experimental Technology 13 Subsidence Control ft. ft.
Geothermal(Closed Loop) 13 Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnev soWrock ins etc
0 rL 13 rt. Clay [ ';
4.Date Well(s)Completed:4/21/21 well ID#322614 13 rL 40 It. Sand'y Overburden
5a.Well Location: 40 It- 52 ft* Weathered Rock
IQ Customs 52 IL 62 rL Solid Rock
Facility/Owner Name Facility ID#(ifapplicable) 70 It 1 73 It' Dirty Vein
302 Fletchers Ridge Rd, Mt Ulla 28125 ft Irt.
Physical Address,City,and Zip ft I ft.
Rowan 551049 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
35 41 42.126 N 80 42 11.318 W Ll
6.Is(are)the well(s)oPermanent or Temporary Signaturb 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: Dyes or lNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: 225 (ft-) 24a.For All 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:20 (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 Infection Wells: In i 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 18 Method of test:Airlift 24c.For Water Sunoly&Infection 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: 10 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
E
{