GW1-2022-06926_Well Construction - GW1_20220603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor information:
Spencer Adams 14 WATER ZONES l;
FROM TO DESCRIPTION
Well Contractor Name 116 i<- 245 R• s cure
4449-A
R. a.
NC Well Contractor Certification Number 'S.OUTER'CASING for mal6 ased'weDs OR LINER if s " ble
Rowan Well Drilling FROM TO DIAMETER TatctavEssI MATERIAL
0 ft. 116 ft- 6114 tO SDR21 PVC
Company Name
13923 lt;;'INNER CASING ORTUBING `eothermafdosed-loo
2.Well Construction Permit# FROM 1 TO 1 DIAMETER I TMCXNnS MATERIAL
List all applicable well construction permits(t.e.WCG County,State.Variance,etc) % R• in.
3.Weil Use(check well use): ft. ft.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE TnrCKNF.SS MaTenrAL
Agricultural OMunicipaMblic ft. ft, in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) R• & in.
IndustriaVCommerciai [31tesidentiai Water Supply(shared) .18.GROUT.,
Irrigation FROM TO MATERIAL EMPLACEMENT MEMOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Haepiuo gravity
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRA1'EI:PACK a iaibie -. `
Aquifer Storage and Recovery 0SEdinity Barrier FROM TO I MATERIAL EMPLACEMENT METAOD
Aquifer Test OStormwater Drainage ft. fi•
Experimental Technology oSubsidence Control ft. R.
Geothermal(Closed Loop) OTracer 20 DRiLLING LOG'stWith additiotut!Sher H
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardam so0/rvck size,etc.
0 fr- 20 R• day
A.Date Well(s)Completed:5/24/22 Well ID#13923 20 ft. B0 ft. > overburdw
5a.Well Location: SA h• 105 R• weadvered rock
Fred&Angela Conger 705 ft- 115 R' solid rock
Facility/Owner Name Facility IDS Cif applicable) tt' it.
330 Canal Rd, Belmont 28012 ft. f
Physical Address,City,and Zip
tt. fr. • v „� ..,.
Gaston a1.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertification: L
3511 9.669 N 81 157.324 W /
,� L t-C
Signature f Certified Well Contractor Dateb.Is(are)the well(s)�it Permanent or'Temporary j
By signing this form.I hereby cerH6;that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: r3Yes or EINo with iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair tattler 4'21 remarks section or on the back of thus jornr. 23.Site diagram or additional well 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: 245 (tl.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing:25 (it.) 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 ofthis 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,Underground injection.Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: air lift 24c.For Water Suoniv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 12 oz completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016