GW1-2022-04519_Well Construction - GW1_20220509

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Spencer Adams 14.WATER BONES i.
Well Contractor Name mom I TO DEsciurnoN
4449-A 108 n 226 if. tam
225 ff' 265 fL a tram
NC Well Contractor Certification Number I&OUTER CASING for mold-m d w�eBs OR I LNER if a 8eable
Rowan Well Drilling FROM TO DIAMETER TUICIavFss MATERIAL
o fa 1 106 fi- 1 6114 ia. SDR 21 PVC
Company Name 16.INNER CASING OR TUBING tbesmal closed400
L Well Construction Permit#:WELL 06 2021 153477 FROM I •ro I DUMETER I TTDcmvess I nIAMMUL
List all applicable well construction permits P.C.WC,Cowry,matA vmiance,etc.) fL f, fa
3.Well Use(check well use): fL
Water supply Well: SCREEN
FROM I TO DIAMETER I SLOT SUE I TMCKNESS I MAT ERUL
Agricultural [3Municipat Public R fL hL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
R R In.
Industriai/Commercial DResidential Water Supply(shared) IL GROUT,
Irrigation FROM To MATERIAL E WMA ME7TIOD&AMOUNT
Non-Water Supply Well: o 04 20 ft, HOLEPLUG GRAVITY 12
Monitoring Recovery 1t. fc
Injection Well:
Aquifer Recharge QGroundwater Remediation R. n
_19.SANINGRAVEL'PACK me
Aquifer Storage and Recovery DSBlttllty Barrier FROM TO I MATERUL I EMPIACEMENT METTIOD
Aquifer Test [3Stormwater Drainage D• tt
Experimental Technology [3Subsidence Control ft. fL
Geothermal(Closed Loop) [3TMccr 20.DRILLING III,LOG attx6 additional dwis If
Geothermal (Heating/Cooling Return) Other( lain under#21 Remarks)I FROM TO ox rotor sowroelc etc.
- 0 2 16 ft. CLAY 4/26/22 153477
4.Date Weil(s)Completed: Wen 1D# 15 fL 75 CLAY/SAND
Sm Wen Location: TO IL s6 fL WEATHERED ROCK
TODD GALLOWAY as & 110e fL SOUD Rock
Facility/OwaerName Facility IDN(ifapplicable) 111 fL in IL SOFTVEINS
4960 SURFWOOD DR,SHERRILLS FORD 28673 fL n
Physical Address,City;and Zip fG tt
CATA"GA 460604846000 21_REMARKS
County Ptacel identification No.(PIN)
Sb.Latitade and longitude in degrees/miantes/see>Bnds or decimal degrees:
,r
(ifw sufficient)
ell field,one Wong is sucient) 22.Certification: ( �� " ` 'i luf
35 33 29.972 N 80 59 19.568 Nm "`,`f`
4 Z-i f 1 7-L
6.b(are)the wen(s)OX Permanent or Temporary Signature ofCertified wellContreaor Daze
By signing this four.I hereby certttfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an e=bft well: 13Yes or Ot No with 15A NCAC 02C.0100 or JSA NCAC 02C.0200 Well Construction Stmxlordr and that a
If this is a repair,Jill out brown well comtruction irrfomation and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the buck of this form 23,Site diagram or additional well details
g.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:r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (10 24a. For Au.Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdij/erent(example-3 a@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 lerel is abo►v casing.use"+" 1617 Man 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 24.
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,eta)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test:Welr 24c.For Water&Wgly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fort within 30 days of
13b.Disinfection type: chlorine Amount. 12 oZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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