GW1-2022-09348_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
205 ft- 235 ft,4449-A raretaed t cws
235 ft* 325 ft. o—twi., 24GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LAVER �a 'livable
Rowan Well Drilling FRODi TO DIAMETER THICKNESS MATERIAL.
0 ft 182 ft- 6114 in.
SDR21 PVC
Company Name
3696 16.INNER CASING OR TUBING eotbermat closed400
2.Well Construction Permit#: TROXI TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN '.
FROM TO DIAMETER SLOT SIZE II THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) It. ft. in
Indltstrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: 0 ft, 20 ft. Holeplug Gravity 31 bags
Monitoring Recovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK fifa livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:'DRILLING LOG attach-additional sheets if necessary)
hGeothermal(Heatin Cooling Retum) 0Other(explain under#21 Remarks) I
FROM To DESCRIPTION color,hardness,soittrock type,min size,etc
0 ft. 12 ft. Clay
4.Date Wells Completed:9/16/22 Well ID#13696 12 ft. 172 ft.
() p Sandy Overburden
5a.Well Location: in ft t82 ft. Solid Rode
Cornerstone III Properties 182 It. Z05 ft. 13rowr Rock Soft
Facility/Owner Name Facility ID9(if applicable) 205 fG m ft. Loos4Gravel
5012 Kings Pinnacle Dr, Kings Mtn 2808E
Physical Address,City,and Zip ft. ft.
AL U
Pr±i t
Gaston 351301 7371 21.REMARKS �-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3511 17.486 N 81 18 26.0t
6.Is(are)the well(s)opermanent or OTemporary Signature'o"fCertified Well Contractor Date
By signing this forni,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constniction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair wider ri21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
S.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: 325 (170 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdieren t(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 50 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
It.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,fUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 Method of test:Airlift 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 15 oz completion of well construction to the county health department of the county
13b.Disinfection type: Amount: P �` P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016