GW1-2021-07967_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 34.-WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 90 ft 100 lit" 4 GM I D111
ft. ft
NC Well Contractor Certification Number "15.1OUTERCASINGff6fr,
Rowan Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
0 ft. 1 45 ft- 1 6 1/4 in. SDR 21 PVC
Company Name
;A6.INNER CASING OR TUBING(geollh
2.Well Construction Permit#: 201800000897 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: -,,17..SCRFEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IgMunicipaVPublic fa ft. in.
—.IGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
.—IIndustrial/Commercial []Residential Water Supply(shared) A&GROUT­
7XIlirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 13 bags
Recovery ft. ft.
,--)Monitoring ORer
Injection Well: fL It.
DAquifer Recharge E]Groundwater Remediation -49.SAND I/GRAVEL'PAC
Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
:)Aquifer Test [3Stonnwater Drainage ft. ft.
:)Experimental Technology [3 Subsidence Control ft. I,
:)Geothermal(Closed Loop) DTracer .!O.DRILLING LOG`(attach additiaiiiiistiei&if.necessary)-,,�,.
DGeothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardviess,soil/o k type,grain si etc.)
0 ft. 10 ft, clay
4.Date Well(s)Completed: 10/21/21 Well[D#201800000897 10 ft. 23 ft' sandy overburden
5a.Well Location: n ft. 35 ft' weathered rock
Marshall Gwynn 35 ft. 45 fit- solid rock
Facility/Owner Name Facility ID#(if applicable) 90 ft. ft' vein dirty 4 GPM NOV 2 2
1585 Gable St, High Point,27262 ft ft.
Physical Address,City,and Zip ft ft. NFOR
Randolph 6799603861 '21.-REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwefl field,one lattlong is sufficient) 22.Certification:
35 55 5.318 N 801 30.745 W 10 121 1-7-1
6.Is(are)the well(s)opermanent or []Temporary Signature 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: Oyes or ONo with 15A 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#21 remarks section or on the back ofthis 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 Ito 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: 405 YL) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiple wells list all depths i(different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above caving,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) 4 Method of test: weir 24c.For Water Supgly&ln&ection Wells: 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: 19 oz completion of well construction tor 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