GW1-2022-08406_Well Construction - GW1_20220420

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14i WATER ZONES
\VellContmetorName FROM TO DESCR1PTIoN
4449-A Soo ft. 345 ft —
345 ft, 405 fit. acva
NC Well Contractor Certification Number 15.OUTER CASING fo mWli-iased:welh`OR LiNER''ifa iciible
Rowan Well Drilling FROM TO DL"JETER T1nZEss aIATEMAL
0 ft- 1 45 fl. 61/4 m SD21 PVC
Company Name
ZOZZOOOOOZ `16i1NNER'CASINGOR:: ING eothermalelosedloo
2.Well Construction Permit#: FROM TO DIAMETER MICKNESS MATERIAL
List all applicable well construction permits(i.e.WC County,State,Variance,etc.) ft ft. im
3.Well Use(check well use): fL ft. in.
Water Supply Well: FROM
FAOaf - TO DIAM1fECER SLOT SIZE THICKNESS AtATERWL
Agricultural []Municipai/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
IndustriallCommercial DResidential Water Supply(shared) J&GROUT
1cri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 & Holepluo Gravity 5
Monitoring F3Rccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundueter Remediation
19.SAND/GRAVEL PACK rf a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO AIATERML I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
i Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -20.DRELLiNG,LOG attac6additiouafabeeis if iieeessaryy
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM To DESCRIMON eolor.hardness,saitf n k type,grain size;etc.
0 ft. 24 ft, Clay/Sand
4.Date Well(s)Completed:3/18/22 Well HM 2022000002 24 ft. 45 ft, Solid Rock
ft. ft.
5a.Well Location:
Albert Brooks ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
3699 Lick Creek Ch Rd, Denton rt. fL
Physical Address,City,and Zip ft. ft.
Davidson
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35 35 29.109 N 80 12 38.2009 W 3
6.Is(are)the well(s)Ox Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair t0 an existing well: QYes or EJNo with 15A NCAC 02C.0100 or 15A A'CAC 02C.0100 iVell Construction Standards and that a
If this is a repair,fill out known well construction information and explain fire nature of the copy ofthis record has been provided to the well owner.
repair corder 1921 remarks section or on the back ol'this form.
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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivel/s list all depths Jfdi(jerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: (ft•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.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 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:Airlift 24c.For Water Supply&infection 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: 19 oz completion of well construction to the county healih department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmentat Quality-Division of Water Resources Revised 2-22-2016