GW1-2021-04371_Well Construction - GW1_20210429

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' Pririt,Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Spencer Adams 14.WATER ZONES
FROM TO I DESCRn'TION
Well Contractor Name
81 R• 425 ft- 3 GPM
4449A 425 R• 805 fL 0 GPM
NC Well Contractor Certification Number 15.OUTER CASING for innitl.cssed hells OR LINER ifs"ilcable).
Rowan Well Drilling FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 R 81 fL 61/4 i0 SDR21 JpVc
202-00002421 16.INNER CASING OR TUBING thermal closed
2.Well Construction Permit# i FROM TO DIAMETER TH1CFW SS MATERIAL
List all applicable)sell construction permlts(I.e.VIC,County,Starr.Variance,a cj R. ft. In.
3.Well Use(check well use): ft R. In.
Water Supply Well: FROM -1To I DIAMETER SLOT SIZE I THICIQPFSS I MATERIAL
Agricultural DMunicipaMblic ff1 0 fL ft. is
Geothermal(Heating(Cooling Supply) ®Residential WaterSuppty(single) R• it In.
Industrial/Commerciat E31tesidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPIACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R- 20 f6 Holeplug Gravity 16 bags
Monitoring ORecovery ft. ft.
Injection Well: 2 ft.
Aquifer Recharge Groundwater Remediati�sn
II '19:SAND/GRAVEL PACK if a n¢able
Aquifer Storage and Recovery OSaliftity Barrier FROM To MATERJAL I EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage 1 rt fL
Experimental Technology 0Subsidence Control I
Geothermal(Closed Loop) OTracer i 2&,DRILLING.LOG atteehadditionalshects'if oecessa
Geothermal eatin Coolin Return Other ex lain under 021 Remarks FROM To DESCRIMON color,htrda rotUmk tym ardo dze,etc
0 rt• 10 ti Boulders/Weathered Rock
4.Date Well(s)Completed:3/9/21 Well IDa20200 2020092421 10 ft• 71 Bouldet rs/Sandy Overburden
Sa.Well Location: j 71 R' 81 R Solid Rock
N Style Construction 1 ff• R
Facility/OaverName Facility ID#(ifopplicatik)
2262 Hulin McDowell Rd, Denton 27�39 R• ft.
Physical Address,City,and Zip
Randolph 6780688035 2L REMARKS
County Parcel Identification No.(PIN)
Sit.Latitude and longitude in degrees/mMates/seconds or decimal degrees: ON
(ifweli field one tat/long is sufficient) I. 22.Certification:
35 41 41.165 N 80.248.310
6.1s(are)the well(s)E Permanent or Temporary i Signahue of Certified 1Ve11 Contractor Date
By sgntng this farm,I hereby certify that the wells)%as(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JMNo udth 1 SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
/fthis is a repair,fill out known well construction information and explain the noium of the copy of this record has been provided to the nell 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 th4 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:t j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: $OS f (fW 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple%,ells list all depths ifdiA'erent(example-3@200'and 2@I00') i construction to the following:
10.Static water level below top of casing: i (ft.) Division of Water Resources,Information Processing Unit,
if water level is above Basin use"+^ I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) Z4b.)for Iniection WellsIniection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this fort within 30 days of completion of well
12.Well construction method: 1 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
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13a.Yield(gpm)3 Method of test:Airlift 24c.For Water SDDDIV&Infection Wells: In addition to sending the form to
Chlorine 51bs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount 1. completion of well construction to;the county health department of the county
where constructed.
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Form GW-1 North Carolina Departmcn(of Environmental Quality-Division of Warn Resources Revised 2.22-2016
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