GW1-2022-06899_Well Construction - GW1_20220718

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gi
Spencer Adams '44.-WATERZONM:
Well Contra tor Name FROM TO D
rSCRKPTION 9-A 76 ft. 150 ft' 2GPM
444
150 ft' 405 SGPM
NC Well Contractor Certification Number
Rowan Well Drilling FROM i TO I DIAMETER THICKNESS MATERIAL
0 ft. 1 76 ft. 1 6114 . SDR21 PVC
Company Name
16':INNER 'AS JBING(agotherrhO doscd4dool
2.Well Construction Permit#: 13666 FROlf TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,Rate,Vanance,etc) ft. in.
3.Well Use(cheek.well use): ft. ft. in.
Water Supply Well: 17:SCREEN�FROM TO DL&METER SLOT SIZE I THICKNESS I MATERIAL
Agricultural OMunicipaMblic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft, i,in.
Industrial(Commercial [3Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 Holep(-g Gravity 8 bags
3Monitoring [3Recovery ft. &
Injection Well: ft. it.
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
I • i
Geothermal(Closed Loop) E)Tracer ".20.'DRIL
FROM TO DESCRIMON(color,hardaa%soiVmck W, .I.SiM dr-)
Geothermal(Heati Coolie Return) MOther.(explain under#21 Remarks) I
0 ft. 10 ft- Clay
4.Date Well(s)Completed:611/22 wen ID#13666 10 ft- 45 ft. sandy Overburden
Sa.Well Location: 45 ft. 76 ft. Sorja Rock
Monique Sullivan fL I I % -
Facility/Owner Name Facility W#(ifapplicable) % &
1549 Ike Brooks Dr, Kings Mtn & to P P r,P—rk I r_
Physical Address,City,and Zip ft. ft.
Gaston 3515 26 8072
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeYminates/seconds or decimal degrees:
Fi111_11P�EIM21-11`11rllp�URI;
ti(if well field,one lat/loug is sufficient) 22. 7i
35 15 20.040 N 81 18 6.546 Q
Signature of Certified Well Contract�r, Date
6.Is(are)the well(s)OPernument or Temporary I �
By signing this form,I hereby certify that the irell(s)was(were)constructed In accordance
7.Is this a repair to an existing well: 13Yes or JMNo with 15A NCAC 02C.0100 or 15A JVCAC 02C.0200 Well Construction&andards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provide d to the well onwer.
repair under 421 remarks section or on the back of this fann. 23.Site diagram or additional,well details:
8.For Geoprobc/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-I is needed. Indicate TOTALNUMBER of wells construction details. You may a I lso attach additional pages if necessary.
drilled- SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface: 405 24a. For All Wells Submits this form within 30 days of completion of well
r,,r multiple wells list all depilisifdiffermt([e-mail] 2@100) construction to the following. I
10.Static water level below top of casing: (ft.) Division ofWater Resources,Information Processing Unit,
Ywater level is above casing,use"+" 1617 Mail Servii.e,Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Inwectton Wells Inladdition 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: J
(i.e.auger,rotary,cable,directpush.etc.)
Division of Water Resoukes,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test Airlift 24c.For Water Sumly&liketion Wells: In addition to sending the form to
the address(es) above, also s6binit one copy of this form within 30 days of
13b.Disinfection type. Chlorine Amount. 19 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 222-2016