GW1-2022-03130_Well Construction - GW1_20220307

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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
445 ft 485 ft, aocvui '
4449-A
ft. ft
NC Well Contractor Certification Number 15:OUTER CASING for mutes-casd wells e OR LINER.ifa 'licable
Rowan Well Drilling FROM To DIAMETER r®cicvFssI MATERIAL
ft. 1 87 ft- 61/4 1°' W,21 pvc
Company Name
10012803 16.INNER CASING OR;TIDBING eodrecmal closed-lao
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell constriction permits(r.e.U1C,County.State,Variance,ere.) ft. ft. is
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROMCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) 1&GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fL 87 ft. EZ SEAL Pump 8
Monitoring Recovery ft. ft
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
r9..SAND/6RAVEL PACK(if a ticable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [3Stonnwater Drainage ft tt
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG aitre4 additional slxets if necesaa
Geothermal Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DEscweTroN(color,ha.d sciurock m eta
o ft 20 ft. day
2/17122 10012803 ft. ft
4.Date Well(s)Completed: Well iI)# zo so sandy overburden
Sa.Well Location: so ft. 77 ft' weathered rock , � E
Koval Builders 77 ft- 87 ft- solid rock
Pacility/Otrver Name Facility iD#(ifapplicable) f ft
2942 Burgess Dr, Charlotte 28208 ft. ft.
Physical Address,City,and Zip ft ft. 3n
Mecklenburg 145 221 25 21.REMARKS"
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 22.Certification:
35 12 24.261 N 8o5413.285 W 2-11-712 a
6.Is(are)the vrell(s)OPermanent or OTemporary
SignatAre ofCertified Well Contractor Date
By signing this form,1 hereby cerltf�that the wells)is-as(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knmrn well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under t121 remarks section or on the back of tlnds farm. 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: 505 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 200 and 2@100') construction t0 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 forth 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) 30 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: 23 oZ completion of well construction ito the county health department of the county
where constructed
Fan,GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016