GW1-2022-08838_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams -14.WATER ZONES.
Well Contractor Name 17I1011 TO DESCRIPTION
4449-A ss ft. 30D ft. 4 GPM
395 ft. 425 ft' 36 GPM
NC Well Contractor Certification Number 15..OUTEWCASLNG for multi=eased wells .OR LINER if a' licahle "
Rowan Well Drilling FRONT TO DIAMETER THICKNESS MiATERiAL
Company Name D ft. 86 ft. 6114 In' I SDR 21 1 PVC
373425 16 INNER CASING OR TUBING( eothermat closed-loon) •
2.Well Construction Permit#' FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well consiruction pennits(i.e.UIC,County,State,Yariaaca,etc'.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17..SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial O'Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMIENT METHOD&AMIOUNT
Non-Water Supply Well: 0 ft. 20 ft. holeplug gravity 20 bags
Monitoring QRecovery ft. ft.
Injection Nell:
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier 19.SANDIGRAVEL PACK if alicableFROM TO MATERIAL —EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.'DRILLING.LOG attach additional.sheiets if necessary)
p
FROM TO DESCRIPTION color,hardness,soiUrock y e, rain size,etc.
' Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
D ft. 18 ft, red Gay
4.Date Wells Completed:7/22/22 Well ID#373425 18 ft. 70 ft.
P sandy overburden
5a.Well Location: ,a ft. 76 ft weathered rock
Nyi Nlyint 76 ft. 86 ft. solid rock
Facility/Owner Name Facility M9(ifapplicable) 88 ft. 93 ft. fractured rock - s
0 Hewitt Rd, Cleveland 27013 890 ft. 425 ft. major fracture `'--'' - is r
Physical Address,City,and Zip
ft. ft.
Rowan 262 030 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laf/long is sufficient) 22 Certification:
35 44 3.412 80 44 28.999
N W �--� � 1 2 Z �ZZ
6.Is(are)the well(s)IR Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that ilia well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15A NCAC 01C.0100 or 15AA'CAC 02C.0200 lVell Construction Standards and that a
If ills•is a repair,ill out lrnoiwi ivL'1l construction information and explain Ilia nature of the copy of this record has been provided to ilia well owner.
repair corder.421 remarks section or on fire 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 I 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: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtlferent(esample-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,
1f iraler•level is abase casing,use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6 (in.) 24b.For Infection Wells: Ill 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
13s.Yield(gpm) 40 Method of test: air lift 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: 20 oZ completion of well construction to tine 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