GW1-2022-01793_Well Construction - GW1_20220214

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WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES _
Well Contractor Name FROM TO DESCRIPTION
4449-A 134 ft- 625 ft. som
NC Well Contractor Certification Number 740 M 600 % roan
IS.OUTER CAMIIVG for multi=eased wells OR LINER Ff a livable
Rowan Well Drilling FROM To DUMETER THICKNESS MATERIAL
Company Name 0 ff 136 ft- 61/4" so SDR21 PVC
10012580 16.INNER CAM1NGOR'TUBING euther nal eloseda
2.Well Construction Permit#: FROM I To DIAMETER I 71fli mEss I MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) R. R. is
3.Well Use(check well use): R• R:
Water Supply Well: 17.SCREEN
FROM TO I-DUMETERI-1 MATSIIE I Tt1ICIINFSS MATERIAL
Agricultural [3MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. & im
Industrial/Commercial Residential Water Supply(shared) 15,GROUT
1mi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft ft
20 HWeplug Gravity 12 bags
Monitoring DRecovery ft. ft.
Injection Well:
R.
Aquifer Recharge Groundwater Remediation 19 SANDIGRAVELPiACK ft.
ifslicable
Aquifer Storage and Recovery Salinity Barrier -FROM To MATERIAL EMPLACEMENTMETTIOD
Aquifer Test OStormwater Drainage R ffi
Experimental Technology Subsidence Control fL R.
Geothermal(Closed Loop) Tracer 20.DRILLTNG LOG attach*Mfionsl-sheets'if neeessa
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO I DESCRIPTION color,hardness soil= n ens
0 ft. 1s & Clay
4.Date Well(s)Completed: 1/6/22 Well ID#10012580 15 R. too ft- Sandy Overburden
Sa.Well Location: ,W R• 126 R weathered Q
Randy Niassner 126 ft- 136 ft- Solid Rock
Facility/Owner Name Facility iD#(ifopplicable) 760 ft- tso ft' 29 GPM vein t
14501 NC 73 Hwy, Huntersville ft R.
Physical Address,City,and Zip ft. &
Mecklenburg 001 014 20 .21.REMARKS
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 25 41.846 N 80 55 27.985 H,
6.Is(are)the well(s)Ox Permanent or OTemporary SignatureofCertified Well Contractor Date
By signing this form,1 hereby certtfy 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 01C.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#21 remarks section or on the back ofthis 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-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: 805 (it•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi$erent(example-3 tt 00'and 1@100') construction to the following:
10.Static water level below top of casing:45 00 Division of Water Resources,Information Processing Unit,
lfuater 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:
(Le.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) 34 Method of test: Weir 24c.For Water Supply&Injection 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 2.25 tbs completion of well construction tb the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016