GW1-2022-09354_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
245 ft• 280 ft• sow,
4449-A
e, e.
NC Well Contractor Certification Number 15.OUTER CASING"for multi-cased Wells)'OR LINER if a licable
Rowan Well Drilling FROM I TO DIAMETER T THICKNESS MATERIAL
Company Name 0 ft. 1 160 ft- 61/4 j I" SDR21 PVC
13857 16.INNER CASING OR TUBING eothermal dosed-too
2.Well Construction Permit#: FROM To DIAMETER THiCIOESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): f, tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) R g, in.
IndustriaL/Commerciai Residential Water Supply(shared) 18.GROUT.
.irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft. Holeplug Gravity 10 bags
Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Relnediation
19.SAND/GRAVEL PACK if a licable
i. Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa"
Geothermal(Hearin Coolin Retum) , ;Other(explain under#21 Remark) FROM TO DESCRIMON color,hardness,soit/rock in size,etc.
0 ft. 10 ff- Clay
4.Date Well(s)Completed:8/30/22 Well ID#13857 10 ft. ISO ft.
Sa.Well Location: 150 fte 160 ft. Solid Rode
Comerstone III Properties 161 IL 240 ft, Sedimentary Rock
Facility/Owner Name Facility ID#(if applicable) 240 ft, aso ft. Gray Rode _
5100 Kings Pinnacle Dr, Kings Mtn 250 ft. 260 ft. sedimentary Rods
Physical Address,City,and Zip 2W ft• 280 ft, Grey Rode
Gaston 3513 01 9707 21.REMARKS 0 20
County Parcel Identification No.(PiN) ! .,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
J ; L)G
(if well field,one lat/long is sufficient) 22.C rtin eatiOo
35 11 21,270 N 81 18 24.831 W
6.is(are)the well(s)�x Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or qNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 1Vell Consruction Standards and drat a
If this is a repair,fill out known well construction m/brmatian and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair wader 1421 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-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: 285 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tr 00'and 2@100) construction to the following:
10.Static water level below top of casing:40 00 Division of Water Resources,Information Processing Unit,
If water level 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: airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forum within 30 days of
13b.Disinfection type: chlorine Amount: 13°Z completion of well construction to the county health department of the county
where constructed.
Form GW4 North Carolina Department of Environmentat Quality-Division of Water Resources Revised 2-22-2016