GW1-2021-07980_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4449-A 180 ft- 205' ft- 0Ge
205 it• 245 ft' 7ocau
NC Well Contractor Certification Number 1S.OUTER CASING for multi-cased wells OR LINER if a licable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name o ft 1 176 ft 1 6 114 1O SDR 21 PVC
198868 16.INNER CASING OR TUBING(geothermal closed-looril
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
last all applicable welt construction permits(t.e.UIC,County,Sate,114riance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
rFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it. R in.
industrial/Commercial [)Residential Water Supply(shared) 18-GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity
Monitoring QRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SANDGRAVEL PACK if a licable
- Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL 7 EMPLACEMENT METHOD
Aquifer"Test C)Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,suitlrock type,grain sae•ere
0 ft. 25 ft, Gay
4.Date Well(s)Completed:9/28/21 Well ID#198868 25 ft. 100 ft' sandy overburden
5a.Well Location: im ft. 166 ft' weathered rock
Sam Fowler 166 ft. 176 iL solid rock M
Facility/Owner Name Facility ID#(if applicable) 180 tt• '6 tt• vein/dirty a v
1830 NC 152, China Grove 28023 215ft 223 tt vein dirty NOV
Physical Address,City,and Zip ft. ft.
Rowan 126 009 21.REMARKS if 7 Sr'l`.-lr'N i
County Parcel Identification No.(PiN) ,kORMATION P4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 33 56.720 N 80 32 9.264 W 5f-)" FLs�� at '2g 1
6.Is(are)the well(s) x Permanent or OTemporary Signature of Certified Well Contractor Date
By.signing this Dorm,I hereby cerlfJy that Tire irell(s)u•as(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or X)No ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a
/fthts is a repair,fill out known hell construction information and explain the rrature oJ7he copy of this record has been provided to the ivell owner.
repair under:i21 remarks section or an the back of!Iris 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii&rent(example-3La1200'and 2C101)') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifirater level is above caring,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) 30 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: 14 oz completion of well construction to the county health department of the county
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016