GW1-2022-08428_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.NVATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
4449-A 445 ft. rigs ft• 6GPM
ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR LINER if a livable
Rowan Well Drilling FROM TO DIAMETER THICKNESS oATERIAL
0 ft. 87 it. 6114 in SDR21 PVC
Company Name ,t
2022000014 16.INNER CASING OR TUBING eothermal closed-log
2.Well.Construction Permit#: FROaI TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.a.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply WeIL• 17:SCREEN
Agricultural QMunicipallPublic
FROM TO DIAMETER SLOT SIZE THICIMESS MATERIAL
ft. ft. in.
Geothermal(Heating/Cooling Supply) "Residential Water Supply(single) ft. ft. in
Industrial/Commercial OResidential Water Supply(shared) 1&GROUT
Irrigation FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holeplug Gravity 12
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK ifa liable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACENIENT sIEMOD
i Aquifer Test OStormwater Drainage ft. fr.
Experimental Technology OSubs.idence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if i ecessa
FROM TO DESCRIPTION cotor,hardness,soillrock e, in size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 12 ft. clay
4.Date Well(s)Completed:7/8/2022 Well ID#2022000014 12 ft, 57 ft' sandyoverburden
5a.Well Location: sr ft. 67 It.
solidrock
Nicholas Jessee fL ft.
Facility/Owner Name Facility IDb(if applicable) ft. ft.
r
Bridle Creek Trail, Lexington ft. ft.
Physical Address,City,and Zip ft. ft. AUG. r 9 202
Davidson 2L REMARKS
Iriivfrr5 �3n f ✓:: Tint
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35 48 16.262 N 80 25 32.317 W -D" ""` ----
l `Y� ar zz.
6.Is(are)the well(s)EX Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or_ 1JG No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards mid that a
If this is a repair,fill out!mown well construction n formation and erplaiu ilia nature of the copy of this record has been provided to the well owner.
repair tinder 421 remarks section or an!lie 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-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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3@200'mid 2@I001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If waterlevel 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&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: 22 Oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEnviroamental Quality-Division of Water Resources Revised 2-22-2016