GW1-2022-00899_Well Construction - GW1_20220107

Print Form,T
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams .*MATERZONES. -.- .
Well Contractor Name FROM TO DESCRIPTION
165 fL 195 ft- era,
4449-A
260 ft' 325 ft rcvn
NC Well Contractor Certification Number A&OUTER CASING f0a malfi-cased wells OR'LtNER if a iJficable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 151 fL61/4 rn• SDR21 i PVC
Company Name _ _
;76:INNER'G.45ING"OR TUBING `eothermal closed-loo -
2.Well Construction Permit#: NA FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) It, ft. is
3.Well Use(check well use): M ft. in.
Water Supply Well: 17-SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)MunicipaUPublic ft. ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in-
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
X_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft Holeplug Gravity 8 bags
Monitoring []Recovery ft. ft.
Injection Well: R fL
Aquifer Recharge 13Groundwater Remediation
"'l9.SAND/GRAVEL*PACK ifa "livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
i Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.:DRILLING 1,001111 ttach additionatshcets if access
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DEscRwTioN color,na,a0es9 soiurock 0 S etc.
)0 ft. 24 fL Clay '
4.Date Well(s)Completed: 12/27/21 Well ID#NA 24 ft 130 ft
Sandy Overburden
5a.Well Location: rso ft• 141 ft. Weathered Rock
Pete Hadiaris 141 fL 151 ft* Solid Rock 11 ¢¢
Facility/Owner Name Facility ID#(if applicable) 162 ft, Irk ft. Dirty Vein a If y n _J
1642 NC 73, Iron Station 28080 ft. ft.
Physical Address,City,and Zip M ft- -
Lincoln 2L`REh1ARKS ri•� -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
35 28 8.409 N 81 103.177 W '
6.Is(are)the well(s)E)Permanent or Temporary SignattW of Certified Well Contractor Date
By signing this form,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 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMMAL INSTRUCTIONS
9.Total well depth below land surface: 325 00 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00) Construction to the following:
10.Static water level below top of casing: 18 (fL) 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 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) 15 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: 16 0z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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