GW1-2021-07931_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER-ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 235 ft 250 ft rcvrn
fL fL
NC Well Contractor Certification Number 15.OUTER'CASING for multi cased wells OR LINER;if a 'ticable
Rowan Well Drilling FROM TO DIAMETER THIMESS MATERIAL
Company Name
0 ft. 96 ft' 61/4 in- I SDR21 PVC
13569 �t6;INNER CA$INGORTUSING eothermalclosea-too � -
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): ft. ff. in•
Water Supply Well: FROM TO DIAMETERSLOT SIZE THICKNESS MATERIAL w
Agricultural []MunicipaUPublic fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
_'IndustriaUCommercial OResidential Water Supply(shared) 18.'GROUT;
_ 1 1rrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Holeplug Gravity 10 bags
Monitoring 3 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK applicable)
Aquifer Storage and Recovery E]Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
Aquifer Test E]Storm water Drainage ft. ft.
_ Experimental Technology 13Subsidence Control ft ft.
Geothermal(Closed Loop) C]Tracer 20.:DRELLING.LOG,attachaddition i;heetsifnecessa k,;�; ,
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiltmek type,grain s' etc
0 ft. 20 ft- day
4.Date Well(s)Completed:9/15/21 Well ID#13569 20 ft. 70 IL sandy overburden
5a.Well Location. rp ft. 66 ft' weathered rock
Stephen McCarn 66 fL 96 ft solid rock
Facility/Owner Name Facility ID#(if applicable) ft. ft.
38 Bowen Dr, Belmont 28012 ff. ft NOV 2
Physical Address,City,and Zip fL ft
Gaston
IP:T1RP'!AT10 ,v
County Parcel Identification No.(PIN) Uqjf
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
35 13 5.638 N 81 129.437 W
6.Is(are)the well(s)�X Permanent or Temporary Signature ofCertified Well Contractor Date
By signing this form,1 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
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereni(example-3@200'and 2 a 1001 construction to the following:
10.Static water level below top of casing: 30 (ft-) Division of Water Resources,Information Processing Unit,
lfwater level is above caring,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 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: 13 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