GW1-2022-06900_Well Construction - GW1_20220718

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I i
1.Well Contractor Information:
Spencer Adams 14:WATE&ZONES 1. !
Well Contractor Name , FROM TO DESCRHFION
4449 A 310 ft. 385 ft. pis
ft ft.
NC R'e(1 Contractor Certification Number IS OUTER;CASING:formulN ca3ed'iveJl§ OR LINER;if a Gcable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 78 ft, 61/4 l 1° sd21 pvc
Company Name '
2021056 16JNNER'CASING OR Ti1BING. eothermal closed Ioo ;:
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well constnrctiom permits ri.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. Fr. i, is
i.IVSCREEN -
Water Supply Well: '
FROM TO DIAMETER I SLOT SIZE THICKNESS \]ATERffiL
Agricultural [Municipal/Public ft. ft. in.
Geothermal(Heating(Cooling Supply) OResidential Water Supply(single) 7 It. ft. in
Industrial/Commercial DResidential Water Supply(shared)
IS.GROUT :.... _
7-11firigation FROM TO MATERIAL EIIIPLACEME.NI'METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft holeplug gravity 10
Monitoring Recovery ft. ft
Injection Well:
tr. ft.Aquifer Recharge Groundwater Remediation
,19.SAND/GRAVE1iPAc if applicable)
Aquifer Stooge and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACE%IENT:f1ETIIOD
Aquifer Test. [Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
RGeothermal(Closed Loop) Tracer 20.DRILLING•LOG`att�ch additionetstieets ifnet es
GeothermaL(Heating/Cooiin Return) Other(explain under#21 Remarks) FROM TO DESCRIPnON rnlnrtnnrdness,s-W-ek a • 5 etc.
0 ft. 15 ft* day/shale �
4.Date Well(s)Completed:6/27/22 Well ID#2021056 15 ft. 29 ft I o'
ZUZZ
shale/weathe rode
5a.Well Location: 29 ft- 68 ft. weathered rock ,J U L
Tiger Dog Builders 68 ft. 76 ft. solidrodi
ft. ft liktZ .oT"
Facility/Owner Name T:acilityIDA(ifapplicable) r.,1 t^G r UNIT
6421 Weeping Willow Ct, Belews Crk 27009 ft. ft.
Physical Address,City,and Zip ft. ft.
Forysth
21 RE117ARK5:.` ' :. ._ ,... ... .:
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longissufficient) 2 Certification
36 13 2.379 N 80255.431 `v
6.Is(are)the well(s)opermanent or [!Temporary Signature of Certified Well Contractor I Date
By signing this form,I hereby certify flint the uell(s)fray(were)constructed in accordance
7.Is this a repair to an existing well: [Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and drat a
Iffhis is a repair,fill out known well construction it formation and erplabt the nature of the copy of this record has been provided to the well owner.
repair:ruder ill/remarks section or on the back of thisform. !'
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-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: 385 VO 24a. For All Wells: Submit this form within 30 days of completion of well
I'armnitiple wells list all depilrs if different(example-3@200'and 2@100') COnStiUCtlOn to the f011Owing:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"N' 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form\6rithin 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) 3 Method of test: Welr 24c.For Water Supply&Injection 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: 18 oz completion of well construction to the county health department of the county
where constructed. j
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016