GW1-2021-07971_Well Construction - GW1_20211122

--Print Form"
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams J4.WATER ZONFS
Well Contractor Name FROM TO DESCRIPTION
4449-A
145 ft- 285 rL
115 ft- 145 ft aeerk
-
NC Well Contractor Certification Number
515.',OUTERCASING(for LIM1.1&Afaliftlel
TiffE_
Rowan Well Drilling FROM TO MATERIAL
0 fL 104 ft- 61/4 SDR 21 PVC
Company Name
�116.'RqNER CASING OR T ING-.f2eoth6rnaa1'dmed4o66)
2.Well Construction Permit#: 355818 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft HL
3.Well Use(check well use): ft. ft. in.
"17.SC-REEN�Iz,�,'7 -�,f
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESSMATERIAL
:)Agricultural OMunicipaVPublic ft ft in.
—IGeothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft ft in.
IndustriaUCommercial []Residential Water Supply(shared) 18rGROUT�,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
J
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 5 bags
:-)Monitoring DRecovery ft. It.
Injection Well: ft. IL
Aquifer Recharge DGroundwater Remediation
`rlg.,SAND/GRAVEUPACK(ifA'p6li66]e)4.1--"-".
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage fL
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additi
Geothermal(Heating/Cooling Return) r)Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soill k type,Zrain size,We.;
0 ft. 5 fL day
4.Date Well(s)Completed:8/26/21 Well tD#355818 5 ft. 80 f' sandy overburden
5a.Well Location: ft. 94 ft' weathered rock
Micah Vandyke 94 ft 104 ft solid rock NOV 2 2 M!
Facility/Owner Name Facility ID#(if applicable) % ft. yun qrrTlf)hl
0 Molasses Mill Rd,Woodleaf 27054 ft. ft. UVM V­--SING
I;IN
Physical Address,City,and Zip ft ft.
Rowan 808008 '11 REMARKS'�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwefl field,one]at/long is sufficient) 22.Certification:
35 46 36.411 N 80 32 11.338 W -04
6.Is(are)the well(s)oPermanent or OTemporary Signature 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
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 921 remarks section or on the back of'this form. 23.Site diagram or additional well details:
S.For GeoprobelDPT 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: 325 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths itd(fferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use 11+11 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) 5 Method of test: Weir 24c.For Water Supply&Infection 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: 17 oz 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