GW1-2021-07921_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams J4:WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
4449-A 47 ft• 185 ft• z cvm
185 ft 265 ft. scvs+
NC Well Contractor Certification Number 15.-OUTER CASING for.multi-cased well's ORZINER.if a'" ticatile "
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 It, 47 fL 61/4 rn SDR 21 PVC
Company Name
2021000001
�� ����� &'INNER"CASINGOR`TUBING 'eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. fL in.
3.Well Use(check well use): ft. ft. it
A7.SCREEN �` r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS' MATERIAL
:]Agricultural n,MunicipaVPublic ft. ft is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) & ft in.
Industrial/Commercial Residential Water Supply(shared) -18 GROITr
_ kri ation FROM TO MATERIAL" EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. Holeplug Grvaity 8 bags
Monitoring ORecovery ft It.
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19:'SAND/GRAVEUPACK ifa licablti
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test
Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach addifioiuds"heeb if necessary)-
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soitf«k IyM grain size,etc
0 ft. 22 fL shale rock
4.Date Wells Completed: 10/27/21 Well ID#2021000001 22 ft 47 ft
() p slate/solid rock
5a.Well Location: ft. ft.
rlft
Rick Jones ft. ft �� o ��
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft
156 Emerald Isle Ct, Lexington 28027 ft ft
Physical Address,City,and Zip ft. ft. , SKID)
Davidson `11..REMARKS .` f.� rar• t ram' �`
,.1 4.,... - ' ' •. v it
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 37 12.639 N 80 13 28.659 W -y _
6.Is(are)the well(s)oPermanent or 13Temporary Signature ofCertified 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: E]Yes or E)No with ISA NCAC 02C.0100 or 15A NCAC 02C.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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 30 00 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 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) 7 Method of test:.weir 24c.For Water SuoDly&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: 16 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