GW1-2021-07926_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14:�WATERZONEs
Well Contractor Name FROM TO I DESCRIPTION
4449-A
200 IL 350 ft rGP/,,
IL ft
NC Well Contractor Certification Number ;YSrOUTER CAIN ells OR LNER Sif a cMaAblTeE RIALw
Rowan Well Drilling FROM O
Company Name 0 ft* 184 fL 61/4 rn. SDR21 PVC
329886 .16ANNERGASING'OR�TUBING 'eo'theimiddd ed400
2.Well Construction Permit th 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. in.
Water Supply Well: 47-SCREEN
FROM TO Y Y DIAMETER SLOT SIZE TRICKINESS MATERIAL
_!Agricultural []Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared) 187`GROUT
Irfi ation FROM TO MATERIAL y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft Holeplug Gravity 39 bags
:-)Monitoring DRecovery ft ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELYACK(ifa Gcable ' "
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20..DRILLING LOG-attach additional sheets if nec'essa , -:
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardcess soiltreck rain s' etc
0 ft. 15 ft- Gay
4.Date Wells Completed: 10/19/21 Well UN 329886 15 ft t74 ft
() p sandy overburden
5a.Well Location: 1. ft. 184 ft- solid rock
Torsten Aeugle 190 ft• 230 fit- fragile rock
Facility/Owner Name Facility ID#(if applicable) ft ft.
314 Fox Trot Ln,Advance 27028 fL ft.
Physical Address,City,and Zip
ft ft. NO
Davie 21:REMARKS,"-`
.
County Parcel Identification No.(PIN) ✓tl n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: vt�llir
(if well field,one latllon is sufficient
( d g ) 22.Certification:
35. 56 36.129 N 80 25 46.209 W
la �ttk. �zl
6.Is(are)the well(s) 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: []Yes 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 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: 385 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifrvater 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
139.Yield(gpm) 7 Method of test: Airlft 24c.For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection type: Chlorine Amount: 19 oz
the address(es) above, also submit one copy of this form within 30 days of
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