GW1-2021-02541_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449A 70 ft. 5 GPM
�• 205 ft. 9 GPM,
NC Well Contractor Certification Number ►5 OUTER CASING for multi,cased wells OR LINER ila ble
Rowan Well Drilling mom ro DIAMETER THICKNESS MATERIAL
0 ft- 3 ft. 6 1/4'1- SDR21 PVC
Company Name 289326
16.BVIHER CASING OR TUBING sotheirrmal closed-loo
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
Uft all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft• ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural [)MunicipallPublic 0 ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) —ft. ;a
Industrial/Commercial E)Residential Water Supply(shared) S.GROUT
"IlffiRation FROM I TO MATERIAL EMPLACEMENT METHOD&AMODNT
Non-Water Supply Well: 0 ft- 20 ft Holep'lug Gravity 12
Monitoring Recovery
Injection Well:
ft. fL
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK itapplicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if inecessar
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color has da soWrm n siae etc
ft• ft• Clay/sand/Shale roc
4.Date Well(s)Completed: 7R/21 Well ID#289326 ft. 43 ft• solid!rock
Sa.Well Location: 70 ft• h• vein/dirty/5 GPM
Seth Mills ft. ft-
Facility/Owner Name Facility iDli(ifapplicable) ft. ft.
0 Barber Rd, Gold Hill 28071 ft. ft. p
Physical Address,City,and Zip ft• ft. c\��
Rowan 539069 21.REMARKS C `'
PA
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees:
(ifwell field,one laNlong is sufficient) 22.Certification:
35 32 42.271 N 80 18 40.433 W ��� ­7 1-) 1
6.Is(are)the well(s)oPermanent or Temporary Signature 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: E)Yes or EINo with ISA NCAC 02C.0100 or 15A NCAC,02C D200 Well Construction Standards and that a
If this it 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 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
construc on,only I GW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 —(ft-) 24a.For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) Construction to the following:
10.Static water level below top of casing: (ft.) 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,dived push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 14 Method of testa Weir 24c.For Water Suvvly&Injection Wells: In addition to sending the form to
Chlorine 15 oz the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016