GW1-2021-07977_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.-WATER,ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 80 ft 110 ft. I -eau
225 fL 235 ft. ncvn
NC Well Contractor Certification Number
15.=OUTER CASING
"'or ra"Iti4aimmills) R if'S
Rowan Well Drilling FROM 1 DIAMETER OR LINER
MATERIAL
Company Name 0 IL 57 fL 1 61/4 '- I SDR21 PVC
356137 16.114NERCASINGORT INGIaeotherinaJI-dosed-loop)
2.Well Construction Permit#: FROM— TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN",,,,,_k
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL_
IlAgricultural .[]Municipal/Public ft. ft in
:)Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) —ft. ft in.
-3 Industrial/Commercial E)Residential Water Supply(shared) 18.GROUT
I I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rL 20 ft. Holeplug Gravity 9 bags
:—)Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
:)Aquifer Recharge oGroundwater Rernediation
'19.SAND/GRAVEV PACK(ife'v`pti6b]e)'-,',r,'
Aquifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage & ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20_DR1LL1NG LOG.(attach addidiiiial Sheets ifileeessar
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfreck type,grain si eta)
10/29/21 356137 0 ft 15 ft, sandy day
4.Date Well(s)Completed: Well ID# 15 ft 57 ft slate solid rock
5a.Well Location: ft. ft.
Robert Moore it ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. W1 V Z Z -2021
15055 Stokes Ferry Rd, Gold Hill 28071 tt ft
Physical Address,City,and Zip ft. f, nor,
-21.REMAR"��--7
Rowan 546014
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latflong is sufficient) 22.Certification:
35. 31 12.760 N 80 1524.187 W
6.Is(are)the well(s)E)Pennanent or OTemporary Signature ofCertified Well Contractor V 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 or JqNo with 15A NCAC 02C.0100 or 15A NCAC 02C-0200 Well Construction Standards and that a
If1his 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: 245 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: (fL) Division of Water Resources,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) 35 Method of test: Airlft 24c.For Water Suvely&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: 20 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