GW1-2021-07979_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams -34-WATFR ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 63 ft- 165 ft
scvu
ft ft
NC Well Contractor Certification Number
.15.'OUTER CASING(fiiii- ed ills)�O%LINER table)
FROM TO *41i DIAMETER IC, if a!
Rowan Well Drilling T11-1AMER THICKNESS MATERIAL
0 60 lit- 6114 1- 1 SDR 21 PVC
Company Name
'16.'U'4NER CASING OR ING(geothiiinal dw
2.Well Construction Perms[#: ed-loop)
362092 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft. fit- in.
3.Well Use(check well use): ft. ft. in.
-17.SCREEN,,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipaUPublic ft. ft in.
.lGeothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft. & irL
' . 1,
Industrial/Commercial ial OResidential Water Supply(shared) -18 GROUT
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Holeplug Gravity
Di Monitoring E]Recovery ft. ft.
Injection Well: ft. ft
3 Aquifer Recharge 13Groundwater Remediation
-
-19.SAND/GRAVF UPACK0fa'PpIk6bleV_'_
3Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test E3 Stormwater Drainage ft. ft.
71Experimental Technology 0 Subsidence Control ft. fL
:31 Geotherrnal(Closed Loop) OTracer '10 DRIMIL
ElGeothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION TON(color,hardness,soiI/rmkty;Z grain size,etc.
0 ft. 17 ft, day
4.Date Well(s)Completed:9/29/21 — Well ID#362092 17 ft. 45 ft sandy overburden
5a.Well Location. 45 ft. 60 ft.
solid rock
Elena Varela 63 ft. 65 fit- vein/stained water 3 GPM V 2 2
Facility/Owner Name Facility ID#(if applicable) ft. ft
326 Freeze Meadow Rd, China Grove 28023 ft. ft.
Physical Address,City,and Zip ft. ft. I
Rowan 221A049
REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22.Certification:
35 36 1.213 N 80 36 34.567 W -5��
6.1s(are)the well(s)opermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerlt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or JqNo with 15A NC4C 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#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-1 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 il'differeni(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing: 32 00 Division of Water Resources,Information Processing Unit,
Ifivaler 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) 8 Method of test: Weir 24c.For Water Supi)lv&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: 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