GW1-2022-04520_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 ZONES.
.
Well Contractor Name FROM TO DESCRIPTION
4449-A 164 n• 285 R• 4G M
285 It" 365 ft sera,
NC Well Contractor Certification Number iS,OUTER CASING fot:mtilN casal'welb"OR LINER if a llesbk
Rowan Well Drilling FROM To DIAMETER THIC7aVtSS MATERIAL
Company Name
0 fL 1 164 fL 1 6114 m I SDR 21 PVC
316175 16 llMlit CASING'OR TUBING` eothermal closes-too
2.Well Construction Permit#: FROM I TO I DIAMETER I THIClavlass MATERIAL.
List all applicable knell construction permits r.e.WC,County,State,Variance,etc.) fG ft is
3.Well Use(check well use): sr. ft. in,
Water Supply Well: 17.SCREEN-,'
FROM I TO I DIAMETER I SLOTSW I TIMCKNESS MATERIAL
Agricultural E)Municipal/Public ft ft in
D. Geothermal(Heating/Cooling Supply) x®Residential Water Supply(single) ft ft• is
Industrial/Commercial Residential Water Supply(shared) 1&;.GROUT
ICrI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R• 22 ft Holeplug Gravity 13 bags
Monitoring Recovery ft. fL
Injection Well: ft
Aquifer Recharge []Groundwater Remediation 19,SAND/GRAVEL'PACB fs ieable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOID
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20:'DRILLING LOG attdckaddidavmtebeetiL if oe�sa
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,bardo soilt,oek tyw,Krah,shm,eta
0 ft. 18 ft Clay
4.Date Well(s)Completed:4/6/22 Well ID#316175 18 ft 90 ft
p Sandy Overburden
5a.Well Location: BD ft. f54 ft- weathered rock
Empire Builders 154 n• 164 e• solid rock
Facility/Owner Name Facility ID# if livable 164 h• an B• sofl brown ' "` r T�
210 Greenbay Rd, Mooresville 28115 R n'
Physical Address,City,and Zip R• ft. MAY 0
Iredell 4627 78 7486 21.REMARKS
County Parcel identification No.(PIN) �bti
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
35 35 54.854 N 80 55 31.979 W
6.Is(are)the well(sJiE)Permanent or Temporary Sign&=of Certified Well Contractor. Date
By signing this form,l hereby certiifyl�that the wells)uwas(were)constructed in accordance
7.Is this a repair to an existing well: oYes or E)No with 15A NCAC 02C.0100 or 15A NCACV2C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out knouti well construction information and explain the nature ofthe ropy ofthis record has been provided to the well owner.
repair under 921 remarks section or on the hack of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 00 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdif)'erent(example-3@200'and 20100) construction t0 the following:
10.Static water level below top of casing:35 (fL) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service'Ceuter,Raleigh,NC 27699-1617
Il.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,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail ServiceCenter,Raleigh,NC 27699-1636
139.Yield(gpm) 9 Method of test: Weir 24c.For Water Supply&Infection 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: 17Oz 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