GW1-2022-08478_Well Construction - GW1_20220420

Print`'Form "=
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name
545 ft 585 fL
4449-A -
s2s ft, s65 'L
NC Well Contractor Certification Number .IS:OUTER;LgIN'G"focmulW ased.wells'OR LINER if a livable '
Rowan Well Drilling FROM TO DIAMETER TmCR14ESS 51ATERUL
0 ft. 123 ft. 61/4 iO SORZt PVC
Company Name
'16::INNER:CASING OR:TUBING eo¢liermal closed-lao .. '. ;
2.Well Construction Permit#: 10012665 FROM 70 DIAMETER TIHCIL\'ESs hIATErtIAL
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. to
ft. ft, in.
3.Well Use(check well use):
17:'SCREEN -...
Water Supply Well: FROM TO I DL►MEFER SLOTSIZ6 I THICKNESS hATERIAL
Agricultural []Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) 1tIResidential Water Supply(single) ft. ft. in.
IndustriaVCommercial Residential Water Supply(shared) 18`GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: o ft. 20 fL Holeplug Gravity 19 bags
-. Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation t9 SAND/GRAVEL PACK ifa '"livable `
- Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EUPLACEM£NThIETHOD
Aquifer Test oStormwater Drainage ft. TO
Experimental Technology OSubsidence Control ft. rt.
Geothermal(Closed Loop) Tracer R20.DRILLING LOG'attaeBadditionatA6Wifiiecess
FROM TO DESCRn'TION color,hastiness soiVsock size etc.
Geothermal(Heating/Cooling Return) Other.(explain under#21 Remarks) 0 ft. 20 ft. clay
314/22 10012665 20 ft. 75 & Sand overburden
4.Date Welt(s)Completed: Well IIT# y
75 ft. 112 ft- weathered rock
Sa.Well Location:
„z ft- ,z3 fr. solid roar
Dan&Mayra Cay►or
I r
Facility/Owner Name FaciGtylDR(ifapplicable) ,C
15005 Ramah Ch Rd, Huntersville 28078
ft. ft.
ft. ft L
Physical Address,City,and Zip
Mecklenburg 011 261-21 21 REMARKS':r'
(PIN)N ti tifi l Ide
ntification o.
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 26 47.671 N 80 47 52.850 W
6.Is(are)the well(s) x Permanent or OTemporary
Signature of Certified Well.Contractor Date
By signing dais.jornr.I hereby certify That Ore neU(s)eras(mere)constructed In accordance
7.Is this a repair to an existing well: E)Yes or x)No with 15A NCAC 02C.0100 or 15A A'CAC 02C.0200 011 Construction Standards and that a
if this is.a repair,fill out known well construction information and explain lire nature of lire copy of this record has been provided to the it-Lit owner.
repair under 921 remarks section or on the back ofthis 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:' SUBMITFAL INSTRUCTIONS
9.Total well depth below land surface: 685 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far nmltiple hells list all depths ifdi#erent(example-3@200'and 2@100) Construction to the following:
10.Static water level below top of casing: (ft Division of Water Resources,Information Processing Unit,
)
If mater 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 Mail Service Center,Raleigh,NC 27699-1636
24
Method of test:Weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Chlorine Amount: 31 ot: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form OW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016