GW1-2021-07941_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Spencer Adams ZONES
Well Contractor Name FROM - TO I-DESCRIPTION
4449-A 230 ft245 ft rcrw
ft ftNC Well Contractor Certification Number
15.DUTER CASING:(for Tul.h�ed;wells)12��'apjticsble)-'
Rowan Well Drilling FROM TO DIAMETER
MATERIAL
0 L 77 It' 61/4 1- 1 SDR 21 PVC
Company Name
J6.4NNER CASING OR ING(keotherfiW-dosed-loop),
2.Well Construction Permit#: EHW1 8-03777 FROM TO - DIAMETER THICKNESS MATERIAL
ri List all applicable well construction permits e.UIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): m It. in.
=47..SCJREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
7JAgricultural nMunicipal/Public ft. ft in
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft ft. in.
Industrial/Commercial OResidential Water Supply(shared) --I&GROUT
,lIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. Holeplug Gravity 11 bags
:-)monitoring [3Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge 13Groundwater Remediation
-3
ppli�19.-SAND/GRAVEL,PACK(if,4c2ible)"s;"_-,..
Aquifer Storage and Recovery 13 Sal in ity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stonriwater Drainage ft. ft.
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) []Tracer --,2O:DRIFLLINGLOG:(attach additioiiglsheiisifittcessaly)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM
TO DESCRIPTION(color,hardness,soil/mck type,grain siw-etc.)
0 ft. 17 ft, red clay
4.Date Well(s)Completed: 10/5/21 Well ID#EHW18-03777 17 ft 67 rt' sandy ov elrburden
5a.Well Location: ft. 77 ft. solid mac
Oriole Bay Properties ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
4885 White Oak Ln, Denver 28078 ft. ft R,F
Physical Address,City,and Zip ft. ft. N01V 2 2
Lincoln 77692 "21.-REMARKS'r-",",�--g,,��,'�',
County Parcel Identification No.(PIN) PlSrCT,0L-,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: EFORMATION PF?nr.Pq, t)N:,
(ifwell field,one lattlong is sufficient) 22.Certification:
35 32 5.192 N 80 57 57.003 W A---L- 1
6.Is(are)the well(s)opermanent or E)Temporary Signat&e ofCerfified 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 orE)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 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifilifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing:30 (ft.) Division of Water Resource%Information Processing Unit,
Ifivater 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
13a.Yield(gpm) 7 Method of test: weir 24c. For Water Supply&Infection Wells: In addition to sending the form to
14 oz chlorine Amount: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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