GW1-2022-08408_Well Construction - GW1_20220420

prat Form:.::°;
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
L Well Contractor Information:
Spencer Adams 14.WATER ZONEs.
Well Contractor Name FROM TO DESCRIPTION
4449-A 88 ft. t85 fL 3GPM
238 ft' 265 ft. lows,
NC Well Contractor Certification Number 15.OUTER CASING'tiir.multrcased welts OR LINER"if 11cBbfe
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 88 ft. 6114 1O SDR 21 PVC
Company Name
2021000075 1GINNER:CASING ORniBING eothermal dosed-loop)
2.Well Construction Permit#: FROM TO WAarETER I THICKNESS MATERWI,
Listall applicable irell construction permits(i.e.UIC County,State,Variance,eta) ft• ft. in.
3.Well Use(check well use): fL ft• in.
Water Supply Nell: 17::SCREEN._:
FROM TO DIAMETER SLOT SE THICKNESS MATERIAL
Agricult IZ
ural []MunicipaVPublic fr. fr. in
( Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) fr. fr. in
Industrial/Commercial OResidential Water Supply(shared)
18 GROUT.
. Irrigation FROM TO MATERLIL EMPLACEMENT.METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. Holeplug Gravity 11 bags
Monitoring QRecovery ft. ft.
Injection Well: tr. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK fi 'licable
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fr.
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) OTracer 20:DRILLING.LOG attach'addittonalsheets ifnecessa
-.Geothermal(Heating(Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION cater,haniness,soiVmck fype in size,etc
0 ft 20 ft* Clay/Sand/Rock
4.Date Weil(s)Completed:3/21/22 Well ID#2021000076 20 ft 76 ft. Shale
5a.Well Location: ,g ft 88 ft. Solid Rock
Jacob Thompson 95 ft. 225 ft- Dirty vein
Facility/Owner Name Facility 1139(ifapplicable) ft. ft
2399 Rocky Cove Lane, Denton ft. fr.
Physical Address,City,and Zip ft. ft. _ ;.'t' } ,.
Davidson 21-REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
35 36 32.184 N 80 12 52.563 w -
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6.Is(are)the well(s)OPermanent or Temporary Signature 6fCcilified Well Contractor Date
By signing this form,I hereby certify that the i ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{Fell Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy of this record has been provided to die well owner.
repair ender!21 remarks section or an the back of 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-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: 265 (10 24a. For All Wells: Submit this form within 30 days of completion of well
For nnnlNple wells list all depths Y d�erent(example-3 a 00'an 2Ca-)100) construction t0 the following:
10.Static water level below top of casing:45 (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 {iD.) 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) 15 Method of test:Air lift 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 12 oz completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016