GW1-2021-07986_Well Construction - GW1_20211122

Print Form=,� '
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
95 ft. 100 ft. SGPM
325 fL 330 ft, "GM
NC Well Contractor Certification Number 15::OUTEWCASING fonmulh-caseil;wells ORLINER if a `Rcable;
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 43 ft 6 1/4 rn' SDR 21 PVC
Company Name
10011679 'I6.INNERCASING'ORTUBING' eothermaLclosed-loa +;. .
2.Well Construction Permit#: 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. fL in.
Water Supply Well: 17.>SCREEN .
FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft ft. in.
:]Geothermal(Heating/Cooling Supply) [DResidential Water Supply(single) fL ft. in
Industrial/Commercial [)Residential Water Supply(shared) I&GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft. Holeplug Gravity 23 bags
__Monitoring DRecovery ft. ft
Injection Well:
fL ft.
:_)Aquifer Recharge IDGroundwater Remediation
'19.SAND/GRAVEL PACK if' Rcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
,'Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. &
Geothermal(Closed Loop) Tracer 24:DRILLING LOG attach addisonalsheets ifnecessa >.
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness a;ilt«k tyM grain s etc.
0 ft. 5 ft. Gay i
4.Date Wells Completed:9/9/21 Well ID#1001 1679 5 ft. 16 ft'() P sandy overburden
5a.Well Location: 18 ft. 25 ft. blavk gravel Q a
Joshua Davey 25 ft 43 ft solid rock A=s', •C r N��� tl�'
Facility/Owner Name Facility ID#(if applicable) 95 ft. ,m ft. dirty vein/5 GPM
8701 Kerns Meadow Ln, Huntersville 28078 325 fr. 330 f, dirty vein/20GPM
Physical Address,City,and Zip ft. ft. C VVR S" r
11
Mecklenburg 015231 26 21:REMARKs r+,, t',47 _^ n
r6 U i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.C rtification:
35 22 6.856 N 80 52 37.602 �,
6.Is(are)the well(s)JBPermanent or Temporary Signature ofCerti—fled We]]]Contractor Date
by signing this Jorm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or E)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 k21 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 1 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: 345 (It-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If,vater 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) 25 Method of test: weir 24c. For Water SuoDly&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: 12 oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20 t 6