GW1-2022-00911_Well Construction - GW1_20220107

Prnt,Form"
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams .14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4449A
145 ft. 185 ft. 3GVM
200 ft, 245 ft 3.sccM
NC Well Contractor Certification Number 15.OUTER CASING tar multi-cash*61h OR'LINER ifa"°&cable -
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 76 ft.
6 1/4 in.
SDR21 PVC
366094 INNER CASING OR TUBING eo'therihal closed46o '
2.Well Construction Permit#: FROM 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: _A7._SCREEN ,-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural C]MunicipaVPublic ft. ft. in.
I. Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) IL ft. in
IndustriaVCommercial Residential Water Supply(shared) 8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 21 bags
_ Monitoring _ Recovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge 13Groundwater Remediation y.SAND/GRAVEL'PACK ifa' licatile=
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
_I Geothermal(Closed Loop) Tracer :20:-DRILLING:LOG attach Addifiotialsheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiuroek type,grain sim etc.
0 ft. 20 ft. Clay
4.Date Wells Completed: 12/1/21 Well ID#366094 20 ft. ss ft() P Sandy Overburden
5a.Well Location: sa ft. 76 ft. Solid Rock
Susan Beaver ft. ft
Facility/Owner Name Facility ID# tfapplicable)
ft. fL (�-�+�
tY ( f le—
ft. }
480 Hall Rd, Mt Ulla 28125 ft. ft
Physical Address,City,and Zip
ft. ft.
Rowan 761 026 21.REMARKS . r#:-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
35 40 51.496 N 80 41 43.205 `,1, 1 LA k I Z(
6.Is(are)the well(s)oPermanent or OTemporary Signatfire 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: E]Yes or QNo 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 1 GW-1 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: 245 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 2@100') construction to the following:
10.Static water level below top of casing: (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) 6.5 Method of test: weir 24c.For Water SuDnly&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: 17 oz 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