GW1-2021-07936_Well Construction - GW1_20211122

Pnnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams _
Well Contractor Name FROM TO DESCRIPTION
4449-A 230 IL 245 ft- ,Goa
345 ft* 365 fL i oven
NC Well Contractor Certification Number 15:,OUTER GASING"f6r mh cased•wells OR LINER if a licatile "
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 it• 73 ft' 6 1/4 1- SDR 21 PVC
Company Name
310130 �6'INNER CASING OR TUBING "eiitheivlil eliisea lnn x� _:;
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. In.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESSMATERIAL E,
Agricultural []Municipal/Public ft. ft, in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) fL ft. i,c
Industrial/Commercial 0Residential Water Supply(shared) a8.GROUT
Ilrl ation FROM TO r MATERIAL EMPLACEMENT METHOD&AMOUNT~
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 9 bags
:-);Monitoring DRecovery ft. ft.
Injection Well:
tL ft.
Aquifer Recharge Groundwater Remediation
i
i'19::SAND/GRAVEL"PACK'ifi "licable
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD W
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer '40.'DRILLINGLOG.attachaddiiiionilshiitsif iiiegsa
Geothermal Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soft/o k type,grain size,etc.
0 ft. 5 ft. Gay
4.Date Well(s)Completed:9/3/21 Well EN 310130 5 ft. 60 ft' sandy overburden
5a.Well Location: W ft. 63 ft' weathered rook
Northlake Development 63 ft. 73 ft solid rock
Facility/Owner Name Facility ID#(if applicable) 230 ft. Pb ft vein/1 GPM
1150 Fern Hill Rd, Mooresville 28117 345 fr. 350 ft. vein/1 GPM
Physical Address,City,and Zip ft. ft. u 'Vr,SEU I ION
Iredell 4638196294
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 37 44.408 N 80 54 40.672 w e I
6.Is(are)the well(s)fBPermanent or Temporary Signature of Certified Well Contractor Date
By signing this Jorm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes 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: 365 00 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@100') construction to the following:
10.Static water level below top of casing: 00 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 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 C k enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: weir 24c.For Water Sunviv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
ape: Chlorine 15oz completion of well construction to the coup health department of the
13b.Disinfection Amount: P county P county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016