GW1-2021-07933_Well Construction - GW1_20211122

Print Form�T-
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 107 fL Y85 ft. ,rz corn
285 ft. 350 ft z+rz cvm
NC Well Contractor Certification Number J&'OUTER'CASING for multi-ciised 'wells OR LMR if-a `licible
Rowan Well Drilling FROM TO DIAMETER Ta1CIINESS MATERIAL
0 ft- 107 ft6 1/4 in- SDR 21 PVC
Company Name
13112
��.�.�rZ 16 INNER'CASINGOR TUBING `eo`thertitahclosed-loo .. ", _
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. ft. is
-,17.SCREEN
Water Supply Well: FROM TO DIAMETER +SLOT SIZE HICKNESS MATERIAL
_J Agricultural []Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) ;I&GROUT, `
_;Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. Holeplug Gravity 9 bags
_i Monitoring []Recovery It. ft.
Injection Well:
ft. ft.
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL°PACK"if a lieable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology OSubsidence Control tL ft.
Geothermal(Closed Loop) Tracer .20.DRILLING LOG'attaclradditii6iial sheets if recess '
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soilt o k type,grain siw,etc.
0 ft 15 ft, Gay
4.Date Well(s)Completed:9/13/21 Well ID#13112 15 ft. 80 ft sandy overburden
5a.Well Location: w ft. 97 IL weathered rock
Michael Ervin 97 ft. 107 ft. soliidmck r_
Facility/Owner Name Facility rD#(if applicable) ft. ft. if
1140 Oak Crest Trl, Belmont 28012 1L ft.
Physical Address,City,and Zip ft. ft.
Gaston 2L REMARKS"_:`;
County Parcel Identification No.(PIN) PROCESS!NG UP-L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
35 12 7.585 N 81 033.296 W
� /13 lzl
6.Is(are)the well(s)oX'Permanent or Temporary Sign4urc 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 ISA NCAC 02C.0100 or ISA 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 421 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: 445 (fit-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(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,
Ifwater 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) 3 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
136.Disinfection type: Chlorine Amount: 21°Z 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