GW1-2021-08003_Well Construction - GW1_20210809

1.Well Contractor Information: I `
Spencer Adams �, 1° '� ~" 14.WATER ZONES _
Well Contractor Name T°
4449A � �'l. �� ft. ft. 15 GPM
NC Well Contractor Certification Number Qv t� rti•
�� is.OUTER CASING for mutti•cased wells OR LINER if a licable
Rowan Well Drilling o� � mom T° DIAMETER THICKNESS MATERIAL
0 ft. 144 (L 6 T/4 in- SDR21 PVC
r�
Company Name 280874 �� 16.INNER CASING OR TUBING thermal'closed•loo
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. ft. in.
17.
Water Supply Well: FROMCREE TO DIAMETER SLOTSiZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft• ft. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irri ation - FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. Holeplug Gravity 10 bags
Monitoring CIRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control fb ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) FROM TO DESCRIPTION tutor,hardness,soil/mIt t3pe,grain size etc.
6l30/21 280874
ft. rt. Red lay
4.Hate Well(s)Completed: Well1>D# ft. 9 ft. Sandy Overburden
Sa.Well Location: 29 ft. ` ft. Solid Rock
Luke Drechsler ft, ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
897 Hidden View Ln, Cleveland 27013 ft. ft.
Physical Address,City,and Zip ft, ft.
Rowan 257047 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
35 45 17.784 N 80 39 38.412 W
��---- —�_� 13 0 lu
6.Is(are)the well(s)E Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JDNo with ISA NCAC 02C.OI00 or I5A 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
construc�on,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft•) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q/00') Construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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 27699-16M
13a.Yield(gpm) 15 Method of test: Weir 24c.For Water Suppyly&Iniection Wells: In addition to sending the form to
Chlorine 12 oZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction!to the county health department of the county
where constructed.