GW1-2022-04485_Well Construction - GW1_20220509

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Pr1nt form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use y:
1.Well Contractor information:
Spencer Adams AkWAUR ZONW
Well Contimor Name FROM I TO In SCRI111iON
4449-A 200 n 1 245 R
% n.
NC Well Contractor Ceniseation Nmnber A Oi11'n CASING'for""'a! ':wdlc 01t i iNER r'
Rowan Well Drilling FROM I L:�ORZG
ETER THICKNESS MATERIAL
0 11. j hL SDR 21 PVC
�y Name 328293 1ti.'llcnveR
2.Well Construction Permit N. FROM I TO I DGMETER TMCNWM MATERIAL
List all applicable well construction peisnitt(i.e.WC.Camty.Stare,Variance,ere) R M 1a
3.Well Use(check well use): tt. % to
lCmthermal
Supply Well: IZ SCREEN ;>
cnitwai FROM TO DIAMETER sLoir, TtnCIWESS MATERIAL
�Municipal/Public ft, ft, Inhermal(Heating/Cooling Supply) Residential Water Supply(single) R fL isstrial/Commercial Residential Water Supply(shared)
tion FROM TO MATERML EMFLAC6 METHOD A AMOUNT
Water Supply Well: 0 ft 21 h Holaptug Gm ty a
itoring Recovery ft. ftfon Well:
fL ft.ifer Recharge QGroundwater Remodiation
0.i " RAVBL'PACfer Storage and Recovery OSalinity Barrier FROM TO MATERIAL Effl ACF.MEx'PMETHODfer Test E3Stornwater Drainage tL �rimental Technology Subsidence Control fL tL
hermal(Closed Loop) Tracerhermal (Heating/Cooling Return Other lain under#21 Remarks FROM TO DESCRIPTION ootor heriaesh wBtsock inoy, elm
0 tL 6 fL Clay
4.Date Well(s)Completed:4/22/22 well WN 328293 a (L is ft. Roaa
5a.Well Location: to IL 32 R Gay/sue
Richard Miller 32 ft 41 % weWmvd roan
F=ffi y/Owner Name Fa.ft W#(ifapo-ble) 41 & , R adid rock _ r.....
294 Watkins farm Rd,Woodleaf 27064 73 rL 9 1aredaahlirty cT' ` i Jn
Physical Address;City.and Zip tL ft.
Rowan 806 007 '21 REMAtRiKB.,;
County Pawl Iderr ification No.(PIN)
Sb.Lathade and longitude In degreeVatinutes/seeonds or decimal degrees:
(if well field,one hVlM is sufficient) 22. cation:
35 47 42.679 N 80 33 28.267 W A_
6.h(are)the wen(s)apermanent or ®Temporary Sipmtare ofCeitified Well Contractor Date
By sigMng this jam I hereby-P*that the rvell(s)rrm(avere)com tcted in accordance
7.Is this a repair to an exkft well: ©Yes or @No Wth 1SA NCAC 02C.0100 cr ISA NCAC 01C.0200 Wei!Construction Standards oral that a
if this is a repair,fill our brown well consmxfion M ormattoh and explain the nature afthe copy of this record has been provided to the well mvnff.
repair under 1;21 remarks section or art the back ofthls jam.
23.Site diagram or sdditioaai t+yeU detatL4:
&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 i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMIITAL KWMUCTIONS
9.Total well depth belowland surface: 245 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiple wells list all depths ifdifferem(—mple-3@200 and 2@100) construction to the following:
10.Static water level below top of easing: UP Division of Water Resources,Information Pnomsshrg Unit,
if water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 2709-1617
il.Borehole diameter. 6 (ill.) 246.For Infection Wells In addition to sending the form to the address in 24a
above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
Cm 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 Method of test Mir 24c.For Water Suonly&IniretioD Weiss: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: chlorlm? Amount: 12 oz completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Eoviranmwtal Quality-Division of Water Resomoes Revised 2-22-2016
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