GW1-2022-09357_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ^�
Spencer Adams 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
4449-A e0 tr• 180 ft. ,
180 ft. 325 ft* x GPMNC Well Contractor Certification Number 15.OUfERCASING for.mutti-cased well's OR LINER'if a' likable
Rowan Well Drilling FROM TO DIAMETER TMICIQdESS MATERIAL
0 ff 80 ft' 1 6114 in. sd21 pvc
Company Name
325390 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. tt. is
Water Supply Well: 17:SCREEN' _
FROM TO DLAMETER SLOT SIZE THICKNESS MATERLL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(I-Ieating/Cooling Supply) •Residential Water Supply(single) fL ft. in.
IndustriaVCommercial DResidential Water Supply(shared) GROUT
ItTI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• holeplug gravity 8
Monitoring [3 Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge iOGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
(- Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
RGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach:additional sheets if necessa
Geothermal(Heating/Cooling Return) nOther(es lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock a a in size,et
0 ft. 19 ft. red clay
4.Date Wells Completed:8/5/22 Well ID#35390 19 ft. 45 ft.
()Com p sandy overburden
5a.Well Location: 's ft. 70 ft' weathered rock
Jose Franciso Tinajero 70 ft. 80 ft* solid rock
Facility/Owner Name Facility ID' (if applicable) 82 ft. 91 ft. fractured 1 soft rock
173 Carlyle Rd, Troutman 28166 ft. ft. "" K.,T ` r .•
Physical Address,City,mid Zip ft. ft. UC I 1 0 2022
Iredell 21.REMARKS
Ina Ur.:
County Parcel Identification No.(PIN) r,r
5b.Latitude and longitude in degrees/minutcs/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35 39 42.043 N 80 52 0.396 W
6.Is(are)the well(s)fX` Permanent or OTemporary Signaturefof Certified Well Contractor Date
By signing this faro,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or x)No with i5A NCAC 02C.0100 or 15A ArCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the 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 1 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 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths if different(example.3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) 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 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
13a.Yield(gpm) 3 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
13b.Disinfection type: chlorine Amount: 15 completion of well construction to time county health department of the county
where constructed.
Form GW I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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