GW1-2021-07938_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: [_Print Form
1.Well Contractor Information:
Spencer Adams 14 WATER ZONES
WCII Contractor Name FROM TO DESCRIPTION
4449-A 425 ft- 445 ft. ,Gm
rt, ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-eased'wells OR LINER ifa Iicable
Rowan Well Drilling FROM TO I DIAMETER I THIC76VE55 MATERIAL
Company Name 0 ft• q9 ft. 6 114 t° I SD R 21 PVC
319995 16.INNER CASING OR TUBING eothermaI closed-lob
2.Well Construction Permit#: FROM 7O DIAMETER THIC►rnEss MATERIAL
List all applicable well constmetion pernnts(i.e.UIC,County,State,1'ariance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
A rICUhUfaI FROM TO DIAMETER SLOT SIZE THrCKNESS MATERIAL
g []Municipal/Public R. ft. in.
Geothermal(Heating/Cooling Supply) x[]Residential Water Supply(single)
ft. ft. I in.
Industrial/Commercial []Residential Water Supply(shared)
18.GROUT -
ohirigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holeplu
ig Gravity 8 bagss
Monitoring []Recovery ft. ft.
Injection Well:
Aquifer Recharge []Groundwater Remediation ft. fr.
Aquifer Storage and Recovery []Salinity Barrier 19.SANDIGR AVE L PACK ifa 'lieable
FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test []Stormwater Drainage fr. tr.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LUG attach additional sttcels if recess
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRI_— rroioq hardne soiurock rrin size,etc.
9/1/21 319995 0 ft. 4 ft• clay/"sand
4.Date Well(s)Completed: Well ID# 4 ft. 39 IL sandyoverburden
5a.Well Location: J9 ft. qg ft. solid rods
Kenneth Humel 53 ft. 55 ft- -'dirty vein cu
Facilitl40wner Name Facility ID#(ifapplicable) ft. ft.
200 Shady Cove Rd, Troutman 28166 ft. ft. T+ cR�,�r� 1 twit'
AlpRocr
Physical Address,City,and Zip ft. ft. 1 q I
Iredell 4730710150 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22. ertification•
35 39 41.935 y 80 53 43.122 W � � I
744,­_
6.Is(are)the well(s)oPermanent or []Temporary Signature fCertified Well Contractor Date
By signing this form,I hereby certify that the trellis)was("'ere)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No tvidt 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well C'onstnrction Stamlards and that a
If'this is a repair,fill out known trell construction it formation and explain the nature of dte copy of7his record has been provided to the well mvner.
repair under�121 remarks section or on the back of this Jarm.
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 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/•'nr multiple u'eNs list all depths rfdi#ereur(example-3 nQ20D'and 2ca I00') construction to 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"I" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Injectiou 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 cable, 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) 4 Method of test: Weir 24c. For Water Sumily&Iniection Rrells: 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: 14 oz completion of well construction to the county health department of the county
wllere constructed.
Form GW-I North Carolina Department ofEnvironrnental Quality-Division of Water Resources Revised 2-22-2016