GW1-2022-09358_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
130 ft, 245 ft• so cvM
4449-A
ft. fL
NC Well Contractor Certification Number 15.OMR-CASING for multi-cased wells,OR LINER if a 'Gcable
Rowan Well Drilling FROMTo DIAMETER 'MCKNESS 1IaTExtni,
Company Name 0 ft• 120 ft. 6114 in- SDR21 PVC
10012153 16.INNER CASING OR.TUBING" eothermal--closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction 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 THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) xIResidential Water Supply(single) g. g in.
IndustriaUCommercial OResidcntial Water Supply(shared)
18::GROUT
,.; Irri ation FROM TO MATERIAL E 7"LACENIENT METHOD&AMOUNT
Non-Water Supply Well: o ft 115 ft. FZ Seal Pump 12
Monitoring Recovery 5 ft 115 ft. Holeplug Gravity 5
Injection Well: ft. it.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sleets if nec
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sofurock type,gmin size,etc.
0 ft. 12 ft* Red Clay
4.Date Wells Completed:8/24/22 Well ID#10013153 t2 ft. 110 ft.
P Sandy Overburden
5a.Well Location: 110 tt' 1�0 IL Solid Rock
Bob Wilson rt. s.
Facility/Owner Name Facility ID#(if applicable) ft. ft
12811 Moores Chape Rd, Charlotte 28214
ft. ft.
Physical Address,City,and Zip ft. ft.
Mecklenburg 053 161 12 21.REMARKS
ris i71711 :i s'
I s.
County Parcel Identification No.(PIN) .^0G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22. ertifieation:
35 15 9.364 N 8104.421 u
214 l u
6.Is(are)the well(s)ff)Permanent or OTcmporary Signature of Certified Well Contractor ! Date
By signing this form,I hereby certify that the well(s)w•av(were)constricted in accordance
7.Is this a repair to an existing well: E)Yes or JqNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of tile copy of this record has been provided to the well owner.
repair under 921 remarks section or on lire back of this fonn.
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:s SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 UW 24a. For All Wells: Submit this form within 30 days of completion of well
1%or multiple wells list all depths if different(example-1@200'and 2@100') construction t0 the following:
10.Static water level below top of casing:25 (ft.) Division of Water Resources,Information Processing Unit,
tf water level is above casing,use"a" 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
t2.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) k
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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33a.Yield(gpm) 10 Method of test: weir 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: 12 oz completion of well construction to the 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
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