GW1-2022-08407_Well Construction - GW1_20220420

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WELL CONSTRUCTION RECORD(G W-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 300 fL 400 fL z`A'
fL
NC Well Contractor Certification Number 15OUTER`CASING f6r.mnldca4ed:weLLs'OR1iNER fe hcable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 fL 56 ft. 61/4 in. SD21 PVC
331864 16:;nvtvERCAsfNGOR°TusltvG' �oibermahctoyea too'
2.Well ConstructionPermit N: FROM I To DIAMETER I TIUCKNEss I MATERL►L
List all applicable well construction perants(i.e.UIC.County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): fr. ft- in
Water SupplyWeIL- .37:'SCREEN.:
FROM TO DIAMETER I SLOT SIZE THICIQVESS MATERIAL
Agricultural E)MunicipaUPublic ft. ft in.
Geothermal(Heating(Cooling Supply) EIResidential Water Supply(single) ft ft. is
Industriavcommercial DResidential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, Holeplug Gravity s
Monitoring _.Recovery ft. fa
Injection Well:
h ft.
Aquifer Recharge Groundwater Remediation
-'19:;SAND/GRAYELPACI@ ifa 'licable "'
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I En>pi ncEtitENTntETHOD
Aquifer Test 13Stormwater Drainage fL ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tmcer 20:'DRILh1NG-LOG attach-additioriahsiusts ifuecess
Geothermal(Heating/Cooling Retam) nOther(explain under 421 Remarks) FROM TO DESCRIPTION colon hardness soiurock sae,etc.
p ft. 20 ft. Clay
4.Date Weil s Completed:3/17/22 Well ED11331864 20 ft. 48 ft.
P Weathered Rock
5a.Well Location: 4B ft. 58 ft. Solid Rods
Stephen Coulston 72 ft. 120 f4 Dirty Vein f-u •: let,r
Facility/Owner Name Facility ID#(ifapplicable)
it. ft.
180 N Gifford Ln, Richfield 28137 fL ft. APR 2 0 2022
Physical Address,City,and Zip fL ft.
Rowan 530 E 073 21 RENIARKS:
County Parcel Identification No.(PIN) ;a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laNlongissufficient) 22.Certification:
35 33 17.971 N 80 12 51.089 H,
6.Is(are)the neli(s)o% Permanent or E3Temporary Signaturf of Certified Well Contractor Date
By signing this forni,1 hereby certify that the x'ell(s)eras(here)constructed in accordance
7.Is this a repair to an existing well: JoYes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 ifel/Construction Standards and that a
If this is a repair,fill out known ivell construction information and explain the nature of the Copy of this record has been provided to the hell corner.
repair under ii21 rernarks section or on lite 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:i SUBMPTTAL INSTRUCTIONS
9.Total well depth below land surface. 605 (it-) 24s. For All Well Submit this form within 30 days of completion of well
Por multiple wells list all depths ifdifferent(example.3@200'and 2@1065 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 Alan Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test:Weir 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: 27 oZ completion of Well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016