GW1-2022-06924_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
Spencer Adams t4 WATM Z0NFS.
FROM TO
Well Contractor Name DFSCPMMnx
133 ft. 345 ft. 4 Does!
4449-A
NC Well Contractor Certification Number :IS:OUTER CASING Wr:mnt6-cased wells UR LINER �f a
Rowan Well Wiling FROM To m'"'ETER THtCIQVESS M►TEttUu
0 f• 133 ft' 61/4 1n- SOR21 PVC
Company Name f6 INNER CASING OR TUBING hikothermal dose 46
2.Well Construction Permit#: 3564 FRoar To DUMEM THICKMMS MATERIAL
List all applicable well construction permits(Le.WC.County,Slate,Variance,etc) tt. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17:=St31EEx -_
FROM TO :...D R SLOT sizz TnICIQIFSS MATERIAL"
Agricultural E3MunicipaMblic ft. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) % g, in.
IndustriaUCommercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fl- 20 ft. Howom Gravity 14
Monitoring Recovery ft. ft.
Injection Well:
ft. tt.
Aquifer Recharge 13Groundwater Remediation '•t9 SAND/GRAVEL PACK a 'licable _
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL ft
Experimental Technology 13Subsidenec Control
i
Geothermal(Closed Loop) QTraccr .20 DRWLING`LOG attach additional aheets f neotmiryl
Geothermal eatin Coolin Return Other lain under#21 Remarks FROM To DEscRlrrlox mbr,hardness,saurock eta
0 ft. 15 R. CteYf
4.Date Well(s)Completed:5/26/22 Well ID#13564 15 fL 123 ft. Sandy Overburden
Sa.Well Location: tzi ft. 133 & Soles Rode
Comerstone III Properties 141 fL 146 rL Dirty Vein
Facility/Owner Name Facility lD#(if applicable) fL R.
Lot#2 Oak Estates Lane,Bessemer City 28016 & ft.
Physical Address,City,and Zip R' R'
Gaston 21.REMARKS
County Parcel Identification No.(PIN) t
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r 0CLN3 Ui\i
(if well field,one lat/long is sufficient) 22.Certification:
35 19 42.371 N 81 15 3.247 yet
S L(o l Z'Z
6.Is(are)the well(s)OPermanent or Temporary Signature f Certified Well Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or QNo with ISA NCAC 02C.0100 or ISA ArCAC 02C.0200 Well Construction Srmrdands and that a
If this is a repair,fill out latown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 1-21 remarks section or on the back of this form.
23.Site diagram or additional'welt details:
8.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 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: 345 (ft•) 24a. For All Wells: Submit this fornn within 30 days of completion of well
For multiple wells list all depths ifdi jerent(—iple-3@200'and 2@100') construction to the following
10.Static water level below top of casing:40 04 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Infection Wells: In addition 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:
(i.e.auger,rotary,cable.direct push,etc.)
Division of Water Resources,UndeMrround Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 4 Method of test: weir 24c.For Water SDDnly&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: 16Oz completion of well construction to the county health department of the county
where constructed
Form GW-i North Carolina Department of Environmental Quality-.Division of Water R.' Revised 2-22-2016