GW1-2022-06496_Well Construction - GW1_20220603

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor information:
Spencer Adams 1�.WATERZ014Es
Well Conuactor Name FROM To DESCREMON
4449-A 225 & 265 ft' .G,"
NC Well Contractor Certification Number 1?`Of)TER CA5iIYG ormohi-easCdf
" *OhlORI.1Nfdt`Ko'
Rowan Well Drilling FROM To bIAMETER TMCKNM MATERIAL
Company Name
o tc 72 to s 114 SDR21 PVC
374176 16.nrulER CASING©R.TTumG, eotbeh6w Ada
2.Well Construction Permit#: FROM To DIAMETER I THICKNESS I MATERIAL
Use all applicable welt constnu.Yiam permits(r.e.UiC Coa so,.Stare,irarionce,etc.) ft ft in.
3.Well Use(check well use): k• ft. In.
Water Sappiy Well: 17JSCt2EEN
FROM I TO DIAMETER sLarsuz TnrCgVFSS MATERIAL
Agricultural [3Municipal/Public & B, hL:
Geothermal(Heating/Cooling Supply) QResidentiai Water Supply(single) ft. It. In.
Industrial(Commerciai [Residential Water Supply(shared) t>1,GRt)iTf -:
Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o It- 20
eplup Gra+rtry 7 bees
Monitoring E31tecovery R R
Injection Well:
ft IL
Aquifer Recharge Groundwater Remediation
19:!SAND/GRAVEI`PAG1t' a ' ieatilc _
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Storrr►water Drainage � fL
Experimental Technology QSubsidence Control fL tL
Geothermal(closed Loop) Tracer so'DRntalve roc attach Addl laheeh u
Geothermal(Fleeti Coolie Return) Other(explain under H21 Remarks FROM TO DESCRIPTION eater sefl/oerc eao.ete.
0 R- 12 � nay �
4.Date Well(s)Completed:5/11/22 Weil ID#374176 12 ft 62 fL Vwa#wred Rode
5a.Well Location: m R 72 & Sofia Rodc
Gary Hall R fG (-"r
Facility/Owner Name Facility ID#(if applicable) ft tL
587 Mt Hall Rd, Cleveland 27013 rt. ft.
Physical Address,City,and Zip ft ft.
�n-tM1 f
Rowan 269108 21 RSMAnres
County Parcel identification No.(PiN) i!':P }.iii l it r I:,1�L J�•u 3 Jf'I'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
35 44 14.245 N 80 38 32.871 W j
6.b(are)the well(s)E)Permanent or Temporary SignaturckfCcitified Well'Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or QNo wills 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,Jill out known well construction information and explain the nature of the copy of das record has been provided to the well owner.
repair under k21 remarks section or on fire back of this form
23.Site diagram or additional well details:
&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:' SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 265 (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2®100') construction to the following:
10.Static water level below top of casing: UP Division of Water Resources,Information Processing Unit,
Ifuater level is above caring,rue••+^ 1617 Mai!Service center,Raleigh.NC 27699-1617
11.Borehole diameter: 6 (ia.) 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test:Airlift 24c.For Water Subnly&InfecNon Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
131L DIsinfecdon type: Chlorine Amount: 13 oz completion of well construction to�the county health department of the county
where constructed.
Form ow-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016