GW1-2021-07920_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GA-1) For Internal USe Only:
1.Well Contractor Information:
Spencer Adams MNVATERS DESCRIPTION
Well Contractor Name ft. 5c,r,4449-A ft. ccveNC Well Contractor Certification Number G for mulH,eased.wells OR LINER if i livable
Rowan Well Drilling FROM To. DIAMETER THICKNESS MATERIAL
o ft, 51 ft' 6114 m' SDR21 PVC
Company Name 16.INNER CAS NG OR TUB aers ermal oors
2016000052A FROM TO` DIA tIETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. is
List all applicable well construction permits(i.e.UIC,Counl,State.Variance,etc.) i
ft. f ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM Pill
DIAMETER SLOT SIZE THICKNESS MATERIAL
( ,Agriculturat oMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared) ill.GROUT
FROM T' MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri anon
Non-Water Supply Well: 0 ft. 20 ft' Holeplug Gravity 5 bags
Monitoring QRecovery ft. i ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundw'ater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM T MATERIAL EMPLACEMENT METHOD
i
Aquifer Test oStorm«ater Drainage ft. ft.
— Experimental Technology ©Subsidence Control ft. i ft.
Geothermal(Closed Loop) Tracer 20.DRILLING OG attach additional sheets if vi"essa
__ FROM T DESCRIPTION color,hardness,sojumk rain size,etc.
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) o ft. 40 ft- Shale Rock
4.Date Well(s)Completed 10/28/21 2016000052A 40 ft. 51 ft. Slate I Solid Rock
Well ID#
ft. ft.
Sa.Well Location: 9g
k. it � �a��P gz
Glynn Wallace
Vacility/OwnerAame
Facility applicable) ft. ft.
NU
26545 S HwY 109, New London 27239 ft. ft' 20
ft. i ft.
Physical Address,City,and Zip UVVA Jt:G�I l'i
Davidson 21.REMA INFORMATION PROCESS NG UNl
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
35. 30 48.434 N 80. 4 2.443 W Jr ,�„_., 10 .1,1 ,ZA
Signature of Certified Well Contractor Date
6.Is(are)the well(s)ElPermanent or [3Temporary
By signing this Jorm,I hereby certify that the rrell(s)it as(is-ere)construcled in accordance
7.Is this a repair to an existing well: Yes or x©No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,Jill out known well construction aforamiin an od explain due nature of the copy of this recoil has been provided to the well on urer.
repair under 421 remarks section or on the back of'this fornr. 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 details. You may also attach additional pages if necnecessary.construction only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAI i INSTRUCTIONS
9.Total well depth below land surface- 265 00 24a. For All t Wells: Submit this form within 30 days of completion of well
For multiple nvetls list all depths ifdifferent(example-3@200'and 2n100') construction to the followine:
10.Static water level below top of casing:30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,tese"-" %J617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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 t8 the following:
(i.e.auger,rotary,cable,direct posh,etc.)
Division T Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Airiff 24c. For Water Sumoly&Injection Wells: In addition to sending the form to
the address(eO above, also submit one copy of this form within 30 days of
Chlorine Amount: 17 Oz completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Font GW-r North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016