GW1-2021-07964_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Contractor Information:
SPENCER ADAMS
Lam' fA 14.WATER ZONES
Well Contractor Name •� FROM 70 DFSCRIPTION
4449A ` •��3 ���� r, VU fL 4 GPM`
NC Well Contractor Certification Number \l�^ �eJ'
p <;yEO � 15.OUTER CASING for multi-cased wells OR LINER iP a livable
ROWAN WELL DRILLING �o� ' FROM TO DIAMETER TRICKNESS MATERIAL
Company Name
0 ft. 5 fL 6 1/4 in SDR21 PVC
357582�`\P 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ix.UIC.County,State,Variance,etc.) ft. n• in.
3.Well Use(check well use): n• It. in.
17.SCREEN
Water Supply Well:
FROM 7'O DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural 13Municipal/Public 0 It It. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. I, In,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fit• HOLEPLI GRAVIM77 15 BAG
Monitoring 13Recovery tt tI
Injection Well:
tL R.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Pa livable
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage B- R•
Experimental Technology D Subsidence Control ft. I,
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatiq&tCooling Return Other(explain under#21 Remarks FROM TO DESCREMOx wlor he soivrock ae
ft tIKLD CLAY
4.Date Well(s)Completed: 6/11/21 WeB ID#357582 fL 40 n- SANDY OVERBURDEN
5a.WeuLocation: 40 ft ft. FRACTURED GRANITE
RANDY BYERLY —ft. 57 Pt
Facility/Owner Name Facility M4(if applicable) 62 It. 68 It. FRACTURED GRANITE
8930 COOLS SPRING RD, WOODLEAF 27054 ft. ft..
Physical Address,City,and Zip B- ft.
ROWAN813 030 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 46 4.199 N 80 35 24.835 W f_ l
,4-J (A
6.Islay*)the well(s)OPermanent or Temporary Signatuit of Certified 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
lfthis 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 details. You may also attach additional pages if necessary.
construlon,only I GW-1 is needed. Indicate TOTAL NUMBER of welts
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 YL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a@200'and 2@100) construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter., 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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
M.Yield(gpm) 4 Method of test- AIRLIFT 24c,For Water Supply&Injection Wells: In addition to sending the form to
CHLORINE 15 OZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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