GW1-2021-00541_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams t4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 85 ft. 120 ft.
4449-A 211 ft. 225 tL s es
NC Well Contractor Certification Number 15.Q1ITER CASING for multi-cased wells OR LINER tf a likable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
-oft 57 It' 1 6114 m SOR21 PVC
Company Name 16.INNER CASING OR TUBING eothernud dosed400
AP-322091 ERO�1 TO DIAaETER 7YtICKNESS MATERIAL
2.Well Construction Permit#: ft, ft. in.
List all applicable ae!1 construction permits(i.e.UIC,County,State,Varimtce,etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipal/Public ft. ft. in.
Geothermai(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lrrl ation Gravity 11 bags
Non-Water Supply Well: 0 ft. 20 ft' Holeplug
Monitoring Recovery ft. h
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation 19.SAND/GRAVEL PACK ifs likable
Aquifer Storage and Recovery }Salinity Barrier FROM ft. TO ft MATERIAL EMPLACEMENT METHOD
I Aquifer Test [3Stormwater Drainage
Experimental Technology
Subsidence Control ft.
Geothemtal(Closed Loop) QTracer m DRILLING LOG attach DESCRIP'Tadditional sheep it aectxsa
FROM TO DESCRIPTION color,hn,dnes soiUroek type.Wsin size ere.
t;,eothermai(Heating/Cooling Return) . Other explain under#21 Remarks) 0 ft. 20 ft• clay
4.Date well(s)Completed 11/23/21 Well IIl#AP-322091 20 It• 30 ft. sandy overburden
ft. 47 It. weathered rock
5a.Well Location:
John Benjamin 47 ft. 57 ft. solid rock
Facility/Owner Name Facility IDt(ifapplicable)
r2l.
ft. U ft dirty veins
ft. ft.
144 Wiltshire Rd, Troutman 28166 A
fL tt.
Physical Address,City,and Zip REMARKSIredell 4740202567 -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient) 80 52 37.475
35 39 40.195 N _
Signature of Certified Well Contractor Date
6.Is(are)the well(s) % Permanent or Temporary
13y signing This form,I hereby certify that the mell(s)u•as(were)cotutnrcted in accordance
7.Is this a repair to an existing well: JYes or x®No x•ith 15A NCAC 02C.0100 or 15A NCAC 112C.0200 Nell Conviniction Standards and that a
,formation and explain the mature of the
copy of this record has been provided to the it-ell owner.
If'this is a repair,fill oul known well construction i
repair under"2l remarks section or on tire hack of this form. 23.Site diagram Or additional well details:
You may use the back of this page to provide additional well site details or well
S.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only l GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 'ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'differenl(example-3g00'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
10.Static a above caving,use 1617 Mail Service Center,Raleigh,NC 27699-1617
if water
11.Borehole diameter.. 6 (►n•) 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
o
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
Method of test=weir24c.For Water Suably&Injection Wells: in addition to sending the form to
13a.Yield(gpm) 8 the address(es) above, also submit one copy of this form within 30 days of
Chlorine Amount: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Farm GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016