GW1-2022-06742_Well Construction - GW1_20220603

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
SpencerAdams 14.WATER ZONES
Well Contractor Name FROM I TO DESCRUP'nOx
4449-A -10 n• toy %
260 1L 285 R 4cw
NC Well ContractorCerti6cationNumber 1S•OUTERGA5ING formntti-caatdveIIs URLINER ifA tale
Rowan Well Drilling FROM TO DIAMETER T6ICKNFSS n1ATERInL
Company Name 0 R' 1 58 ft 6114 J I- I SDR21 PVC
10012947 16 PMR CASMG OR . tbnv 1 aogedaoo
2.Well Construction Permit#: FROM I TO DIAMETER I TNICtWFSS MATERIAL
List all applicable srell construcaon pemrirs("e.LAIC County,State,Mariana¢,erc") & it. is
3.Well Use(check well use): % to in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER `.:qlAirm I TIDCKNESS I MATERIAL
Agricultural E3MunicipaMblic & fL ;rt
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
R. R in
Industrial/Commercial OResidential Water Supply(shared) 1&GROiPf
Irrigation FROM TO ,MATERIAL EMPLACEMENT METRQD a AMOUNT
Non-Water Supply Well: 0 it 20 & Holeptup Gravity a bass
JA
onitoring Recovery R %
ection Well:
tt, ft,quifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK Mcquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPIACEMENTMETHOD
quifer Test OStormwater Drainage &
xperimental Technology QSubsidence Control iL tteothermal(Closed Loop) Tracereothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRnmox fcobr,hardnem adilmik ftg%tryin ske,en.
0 rL 76 ft. clayI ,
4.Date Well(s)Completed:5/20/22 Well HW 10012947 18 ft: 28 R sandy Ov ftrden
Sa.Well Location: Ter rL 68 f4 solid Rode
William&Donna Brooks 63 R 80 ft- Dirty vein
Facility/Owner Name Facility M#(if applicable) R' R ^ "� B.
10600 Hadlow Ct,Charlotte 28208 fr. n
Physical Address,City,and Zip it. $
Mecklenburg 113 251 33 -21•REAMRxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minotesh;econds or decimal degrees:
(if well field,one IaUlong is sufficient) 22. fication:
35 12 55.638 N 80 59 50.105 W Z6+ZZ
6.is(are)the well(s)Mx Permanent or OTemporary Signauue ofCertified Well Contractor Hate
By signing this form.I hereby certify that the uell(s)was(were)constructed in accordance
7.IS this a repair to an existing well: QYes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
trihis is a repair fill out known well construction information and explain the nature of the copy of rMs-card has been provided to the Civil owner.
repair under 421 retnarks section or on the back of ilnsjbrm.
23.Site diagram or additional well details:
S.For GeoprobeNPT 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: 286 (ft) 249, For All Wells: Submit this',form within 30 days of completion of well
For mrduple wells list all depths ifdi8erent(example-3�00'and 2 aUoO� construction to the following:
10.Static water level below top of casing:20 UP Division of Water Resources,Information Processing Unit,
ifumer level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
s
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 form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le,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
139.Yield(gpm) Method of test:Aidift 24c.For Water Sample&IniectiI n Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 13 oz completion of well construction to`the co health department of the
136.Disinfection type. Amonmt: P �' �� county
where constructed i
Form GW-1 North Carotin Depastrnent of Environmental Quality-Division of Water Resources Revised 2-22-2016