GW1-2021-07922_Well Construction - GW1_20211122

Prnf Form P';
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams .,14:'WATERZONES ._
Well Contractor Name FROM TO r DESCRIPTION
4449-A 400 ft430 ft. 120.GRA
ft. ft.NC Well Contractor Certification Number t15.'OUTER CASING;(for multi-cased•wells ORrLINER ifa""ticable
Rowan Well Drilling FROM TO DIAMETER THIC[aVESS MATERIAL
0 fL 112 fL 6 1/4 rn' SDR 21 PVC
Company Name
.��.�.������$ 16:.INNERCASING�OR'TUBING 'eo'ther'malclosedloo ;t°'' .�°,
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): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE I THICKNESS I MATERIAL
Agricultural OMunicipaVPublic ft. ft. in.
_!Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) fL ft. in
Industrial/Commercial DResidential Water Supply(shared) 18.•GROUT
Xi hTi anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 6 bags
:-)Monitoring _ Recovery ft. ft.
Injection Well:
f4 ft.
Aquifer Recharge Groundwater Remediation
`:19.�SAND/GRAVELPACK(if
a likable
_ Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional,"sheets"if ue essa _ as
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillmk rain size,etc.
0 ft 12 ft day
4.Date Well(s)Completed: 10/15/21 well ID#2021000038 12 ft. 102 ft.
p sandy overburden
5a.Well Location: ,m ft. 112 ft. solid rock
Justin Nifong fL ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. n Y a 1
�I
544 Magnolia Way, Lexington 27295 ft. fr. 2 2
Physical Address,City,and Zip IL ft. c
Davidson 21:REMARKS<<-,4 k' -
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 54 56.271 N 80 18 34.837 `,1,
6.Is(are)the well(s)o% Permanent or Temporary Signature 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: Oyes or E]No with 15A 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 ofthe copy of this record has been provided to the well owner.
repair under 921 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-I 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: 445 (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:40 (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 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 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) 120 Method of test: weir 24c.For Water Supply&Injection 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: 22 O2 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016