GW1-2022-08464_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: p I Y,4,
1.Well Contractor information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM I DESCRIPTION
4449-A 44 It- 205 ft. 17CM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING:for multi c-Ased.wells.OR:LINER if a licable
Rowan Well Drilling FRONT TO DIAMETER THICKNESS MATERIAL
p ft. 44 R.Company Name i 61/4 in. SDR21 PVC
21-3`J9 16.INNER CASING OR TUBING eathermalclosed-loo
2.Well Construction Permit#: FROM I To I DLAMETER I THICKNESS ntnTER[AL
List all applicable well consb7rcilon permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft.
Water Supply Well: 17E SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipaYPublic ft. ft. in.
Geothermal(Heating/Cooling Supply)
Residen6al Water Supply(single) g, ft. in.
Industrial/Commercial Residential Water Supply(shared)
Nlrrigation
18:GROUT FROM TO RATEWAL ENIPLACENTEN.r METHOD&AbIOUNT
Non-Water Supply Well: p ft. 20 ft. HOLEPLUG GRAVITY 5
.monitoring Recovery ft. ft.
Injection Well:
ft.
Aquifer Recharge 013roundwater Remediation ft.
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery OSalinily Barrier rROM TO A ATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LO.G attacic'additiouaFshcets if neces3a`:
_.
- t , rain size,etc.
(Heating/Cooling Return) ;_ Other(explain under#21.Remarks) FRONI TO DESCRIPTION color,hardness,soil/rocke
o ft. 18 ft. CLAY
4.Date Wells Completed-4/21/22 Well ID#21-359 18 ft. 44 ft.
P SOLID ROCK
5a.Well Location: 70 ft. 90 ft. . MAJOR VEIN/LARGE ROCK FRACTURE
Michael Irwin - ft. fc.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8404 Foxbridge Dr, Weddington ft. ft.
Physical Address,City,and Zip ft. ft.
Ufllofl 21.REhlARKS' -.:a:i^� r=r »LLIJflti
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
35210.932 N 80 42 12.522
6.Is(are)the well(s)oPermanent or OTemporary Signatur fCertified Well Contractor Date
By signing this form,1 hereby certify that the irel/(s)was(were)consinic•1ed in accordance
7.Is this a repair to an existing well: QYes or XINo with 15A NCAC 02C.0100 or 15A,YCAC 02C.0200 lVell Construction Standards and that a
If this is a repair,fill out iarown well construction information acid explain the mature of the copy of this record has been provided to the well owner.
repair under till remarks section or or the back ofthis form.
23.Site diagram or additional well details:
8.For GeoprobeiDPT 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferenl(example-3@200'and 2@100) construction t0 the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-i" 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:
(Le.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) 17 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
Chlorine 11 oz completion of well construction to the coup health department of the count
13b.Disinfection type: Amount: P t3' P Y
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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