GW1-2021-02562_Well Construction - GW1_20210811

1.Well Contractor Information:
Spencer Adams 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION205 ft. 245 ft. 2 GPM
4449A _7445-ft. 345 ft. 1 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a [icable
Rowan Well Drilling mom TO DIAMETER THICKNESS MATERIAL
0 It. 119 ft. 6 1/4 i-• SDR21 I PVC
Company Name 16.INNER CASING OR TUBING' eothernial closedloo
318094
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0-e.111C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft.
Water Supply Well: FROM & TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft, in
Industrial/Commercial OResidential Water Supply(shared) 1&GROUT
lrri ation - FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 23 bags
Monitoring Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge OGroundwater Remediation
' 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach additional sheets if necessary)
RGeothermal(Heating/Cooling Return) rJOtber(explainunder#21 Remarks) FROM TO DESCRIPTION colon haidness,soil/rock tyix,grain size etc.
07 ft. it. —Clay
4.Date Well(s)Completed: 7/14/21 Well ID# 318094 13 ft. 10G fL Sandy Overburden
Sa.Well Location: 1 QC ft. ft. Solid Rock
Matthew Fulbright ft. ft.
Facility/Owner Name Facility ID#(if applicable) D• D'
1644 Charlotte Hwy, Mooresville 28115 ft. ft.
WrA
Physical Address,City,and Zip
Iredell 4659 42 3384 ZLREMARxs
County Parcel Identification No.(PIN)
Ltd, C P,r�i•O
v(r V Q�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35 38 19.699 N 80 50 8.360 W
6.Is(are)the well(s)Ex Permanent or OTemporary SignaturlIf 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: DYes or x)No with 15A NCAC 02C.0100 or 15A NCAC 02C 0200 Well Construction Standards and that a
If this is a repair,flit 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
constru on,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: 345 (ft-) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths if&ffereni(example-3r7a 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 Injection 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: 16M Mail Service'Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 3 Method of test: Weir 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlorine 18 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.
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