GW1-2021-07923_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.-WATERZONES--,
Well Contractor Name FROM TO DESCRIPTION
64 ft 89 fL 4 GM
4449-A 240 ft 250 ft' 2GM
NC Well Contractor Certification Number -,,15..OUTER CASING'for Tqtiiq.le'd 'e1&;)04jWa0jIi6bIe)-
a
Rowan Well Drilling FROM TO TER MATERIAL
0 L 57 ft' 1 61/4 SDR 21 PVC
Company Name
�36.INNERCASINGOR TUBING(&ot dosed400v)"`_- ;:_'.',
2.Well Construction Permit#: 2021000052 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. im
Water Supply Well: 47.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
JAgricultural nMunicipal/Public ft. ft.
1 is
:-)Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft. ft. in.
Residential Water Supply(shared)Industrial/Commercial A&GROUT
lFROM TO
Irrigation MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft. Holeplug Gravity 10 bags
]Monitoring EIRecovery fl. ft.Injection Well: fL ft.
:_)Aquifer Recharge [3Groundwater Remediation ',49.SAND/GRAVEL'PACK Qfa kf'i''PPIicAb
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer O Test triwater Drainage ft. ft.Stor
—)Experimental Technology []Subsidence Control & ft.
DGeothermal(Closed Loop) E]Tracer �,20.%DRILLINGLOG attach additiotatiheitsifnecesgiiry)��.-'��;��'�,-,,,
nGeothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hat-dness,soil/rock tyrie,gmin size,etc.)
0 ft. 12 fL day
4.Date Well(s)Completed: 10/14/21 Well tD#2021000052 12 ft. 39 ft' sandy overburden
5a.Well Location: n ft. 57 ft. solid rock
Stephanie Myers 64 ft. 89 ft- veins/coloration in water....
Facility/Owner Name Facility JD#(if applicable) ft
385 Crews Lake Rd, Lexington 27295 fL ft.
Physical Address,City,and Zip ft ft. LIU I I
Davidson 11AMMAIIIKS 16N
County Parcel Identification No.(PIN) 1P'7r)muT!r)M nnn'
TSSING To IF
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2:&iflcation:
35 49 56.272 N 80 20 43.248 W
6.Is(are)the well(s)E)Permanent or OTemporary Signature ol'Certified Well Contractor Date
By signing this form,I hereby cerlt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [:]Yes orE)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 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 00 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifiliffereni(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: 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) 6 Method of test: weir 24c.For Water Supply&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: 23 oz 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