GW1-2021-07925_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams aa.rwATER�zorvl �,.t
Well Contractor Name FROM TO DESCRIPTION
4449-A 105 ft. 125 ft. scats
195 ft. 245 ft. scam
NC Well Contractor Certification Number 15 OUTER CASING for multi-cased wells LINER ifa"licible
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 97 It' 61/4 t- 1 SDR21 PVC
Company Name
30nG�� `16.1NNER EASING OR TUBING eothermal closed-loo r `:="
2.Well Construction Permit#: 7 V FROM TO DIAMETER TRICKINESS 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 ,17.-SCREEN'• ,.:' _ _ • ;;; a=
FROM TO DIAMETER: SLOT SIZE TRICKINESS ^MATERIAL
Agricultural []MunicipaUPublic ft. ft. is
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft. ft. in
:)industrial/commercial Residential Water Supply(shared) 1&GROUT'
__ 1rn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Holeplug Gravity 23 bags
Monitoring Recovery ft ft
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEli'PACIC"if a pplictible
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
_'Experimental Technology []Subsidence Control ft ft
.)Geothermal(Closed Loop) OTlacer 20:DRILLING LOG attach additional sheets ifaecess '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUmk . 'n s' etc.)
0 ft. 15 ft Gay
4.Date Well(s)Completed: 10/20/21 Well UW 309613 15 ft. 50 ft
p sandy overburden
5a.Well Location: W ft. 87 ft' weathered rock
Brandon Cheal 87 ft. 97 ft. Solid rock
Facility/Owner Name Facility ID#(ifapplicable) it. ft. t
2324(0)Comatzer Rd,Advance 27006 ft. ft. v`
Physical Address,City,and Zip ft. ft
Davie 5870105231 21.REMARKS
a�u,r ot-1,rl-oh
County Parcel Identification No.(PIN)
� JJIIVU UIVf
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
35. 54 22.382 N 80 26 50.532 W
6.Is(are)the well(s)�IX Permanent or OTemporary Signaturf 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: 13Yes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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-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: 245 (fL) 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@I00) construction t0 the following:
10.Static water level below top of casing: (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 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) 8 Method of test: Airift 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: 16 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