GW1-2022-00904_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 80 ft. too ft. 4 CP
4449-A 255 ft- 275 It. ,G_
NC Well Contractor Certification Number 15.OUTER.CASING Jfoor mulfi-cased wells OR LINER if a livable
FROM TO I DIAMETER
Rowan Well Drilling THICKNESS DfATER1AL
p ft. 7a f6 6114 in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING eotheimal closed-loo
362766 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tr. ft. in
List all applicable well construction permits(i.e.111C,Coung,,State,Variance,etc•)
fL ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS 11tATERLIL
i Agricultural Municipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) ffiResidential Water Supply(single) ft. ft. in
Industrial/Commercial QResidential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPL4CEMENT METHODS,AINOUNT
irri ation
0 ft. 20 ft Holeplug Gravity 17 bags
Non-Water Supply Well:
gGeothermal
ng Recovery ft. ft.
ell: ft. ft.
Recharge Groundwater Remediation 19.SAND/GRAVEL PACK ifa livable
Storage and Recovery Salinity Barrier FROM To n,ATEwAL EMPLACEMENT METHOD
Test
Stormwater Drainage tt• tt.
ental Technology
Subsidence Control rc fL
mal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(cobr,hnrdrress soi0rock rains' etc.
mal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 30 ft. clay
4.Date Well(s)Completed: 12/1/21 Weil ID#362766 30 ft 5o ft. Sandy Overburden
ft. 68 ft. Weathered Rock ,-c. •-.— — // ---
Sa.Well Location: se fr. 78 ft*
SofM Rock
�Y
Hazel &James Morrison
17 anoq
Facility/Owner Name
FacilitylD# ) 86 ft. H h Dirty veins
173 Rodden Rd, Woodleaf 27054 105 ft• 110 ft* Dirty veins
Physical Address,City,and Zip
Rowan
720 051 21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22.Certification:
35 48 44.699 N 80 38 37.191 Z✓� "�� �„ 2. ( t ('
Signature ofCertified Well Contractor Date
6.Is(are)the well(s) Permaoent or Temporary
Hp signing this form,1 hereby certh,that the well(s)was(were)c•onslrocted in accordance
7.
ut known reel/consl ructimr ihrJnrmation and explain the nature of the
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If Is
is a repair,fill our
Is this a repair an existing wet Yes .x No copy of this record has been provided to the well owner.
provided
repair under`21 remarks section or an the back q/'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
8.For Geop Tor Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only
nly I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 285 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple$tells•list all depths q*di/fereha(example-3@200'and 2 21001 construction to the following:
to.Static water level below top of casing' (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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
Method of test weir 24c. For Water Suably&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) 7 the address(es) above, also submit one copy of this form within 30 days of
chlorine Amount' 13 oz completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources