GW1-2022-08404_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATERZOPtEs
Well Contractor Name F_0:1t - TO DESCRIPTION
4449-A 665 ft• 685 ft• o cr1
ft. ft.
NC Well Contractor Certification Number as.OUTER.-CASING for malti-cased4dls OR LINER if a licable
Rowan Well Drilling FR01I TO DTAMETER THICKNESS MATERIAL
0 ft- S4 ft- 6114 in• SDR21 PVC
Company Name
202n000012 t6.INNER CASING OR TUBING(geothermal dosed-too
2.Well Construction Permit#: G FROM TO DIAMETER THICKNESS DIATERIAL
List all applicable well constntction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply 1Ve11 17;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS 11ATERIAL
Agricultural QMunicipaUPublie ft. [t. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fr. ft. in.
•IndustriaUCommercial DResidential Water Supply(shared) -,18:GROUT
Irr1 ation FROM TO MATERIAL EMPLACEMEN-17 METHOD&AMOUNT
Non-Water Supply Well: o ft- 21 ft. Holeplug Gravity 22
j Monitoring ORecovery R. ft.
Injection Well:
ft: ft.
Aquifer Recharge DGroundwater Remediation
__ 19.:SAND/GRAVEGPACK if applicable)-
i. Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL Ell PLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILLING.LOG: attach additional sheets if n&essa4
FROM TO DESCRIPTION color,hardness,soiltrock type, rain size,etc
Geothermal(Heating/Cooling Retum) Other(explain under#t21 Remarks)
0 ft. 18 ft. Clay
4.Date NVell(s)Completed:7/1/22 Well ID#2022000012 18 ft. 74 ft. Sandy overburden
5a.Well Location: 74 ft. 84 ft. Solid Rock
Shane McCullough ft. ft.
FacilitylOAvner Name Facility lD9(if applicable) ft. ft- .9u_, .0 f; $v-•,
501 Old Bud Sink Rd, Lexington ft. ft. e'er '•%�._5 ` t'
Physical Address,City,and Zip ft. ft. u r• 2 9 2022
Davidson 2I.RENTARKS:':
Una
Parcel Identification No.(PIN) l{ O'Yio iE l(nf1C��' 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: #
35 53 56.264 80 12 22.762 f
6.Is(are)the well(S)oPermanent or OTemporary Signaturelof Certified Well Contractor Date f
By signing this farm,I hereby certify that the srell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well constnrction information and explain tite nature of the copy of(his record has been provided to the well owner.
repair under?21 remarks section or an the back ofthisform.
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-I 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: 685 Vt•) 24a. For All Wells: Submit this form within 30 days of completion of well
For undtiple wells list all depths if different(erannple-3@200'and 2 a 100) construction to the following:
10.Static water level below top of casing: (ft.) 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 Iniection 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:
(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) 6 Method of test* weir 24c.For Water Supply&Iniection 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: 32 oz completion of well construction,to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016