GW1-2021-00540_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14,WATERZONES.� ,. s �. z
Well Contractor Name FROM TO DESCRIPTION
4449-A 205 ft• 265 ft• zcvu
350 fL 405 I'L sore
NC Well Contractor Certification Number 15'OUTER`CASING'for'mulfi cased wells ORZINEW if a""Iicable r ,
Rowan Well Drilling FROM TO DIAMETER THICKNESSI MATERIAL
0 IL84 ft' 61/4 in- SDR21 PVC
Company Name
31 5405 3r� I1vNER CASING OR T7BING eotfibrutal closed too .., .
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) It, ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE x THICKNESS MATERIAL,Y
_J Agricultural ®Municipal/Public ft ft im
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 5 bags
:-]Monitoring Recovery ft ft
Injection Well: ft ft
_'Aquifer Recharge Groundwater Remediation
`10.-SAND/GRAWL"PACK ita`livable "'
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2o..DR11 LING LOG attach additiouaUsheets:f necessa
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRLMON color,hardness soillmk type,grain shne,etc.
' 0 ft. 20 fL Clay/Rock Chunk
4.Date Well(s)Completed: 11/10/21 Well ID#315405 20 ft 74 ft Sand/Weathered Rock
5a.Well Location: 74 ft. 84 ft. Solid Rock
Shannon Woodwork ft ft.
Facility/Owner Name Facility ID# if applicable) ft ft.
2293 Mocksville Hwy, Statesville 28625 ft ft.
Physical Address,City,and Zip It. ft 2�21
Iredell 4797024800
21:RGMARKS: :�..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. 51 41.253 N 80.43 4.210 W
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 921 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
Ifwater 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
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) 7 Method of test: Airlft 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: 24 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 2-22-2016