GW1-2022-09375_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
123 ft. 3W ft. ,.s cvu I
4449-A tt. n
NC Well Contractor Certification Number 15.OUTER'CASlNG for multi-cased wells)OR LINER if a i likable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 123 ft- 1 6114 1 in SDR 21 PVC
373694 16.INNER CASING OR TUBING fizetitbermal dosed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THiC"ESS IMATERIAL
Agricultural OMunicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
Irti ation FROM TO MATERIAL EMPLACENfEINT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 15
Monitoring Recovery fL ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK ifn likable
Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL EItPLACEAtEIVf 111ETAOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING'LOG:attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other ex lain under#21 Remarks FROM TO DESCRIPTION color,hardness soiVrock a rain size etc
p ft. 20 ft, red Gay
4.Date Wells Completed:8/10/22 Well ID#373694 20 ft. 110 ft.
()Com p sandy overburden
5a.Well Location: +,o ft. 113 ft. weathered rock
Trallen Homes 113 fL 123 ft. solid rock -.v
Facility/Owner Name Facility IDN(if applicable) ft. R.
1210 Graham Woods Rd, Mt Ulla 28125 tt. ft.
Physical Address,City,and Zip ft. ft.
Rowan 570A014 21.REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification:
35 38 30,457 N 8041 18.433 W
6.is(are)the well(s)Ex Permanent or OTemporary Signature&f Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out loow•h well construction information and explain the nature of the copy of lies record has been provided to the well owner.
repair wider 421 remarks section or on the back,of this farm.
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: 305 UW 24a. For All Wells: Submit this form within 30 days of completion of well
For nwhiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
i
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
{(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) 1.5 Method of test: weir 24c.For Water Sunah•&Iniection Wells: 1n 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: 14 o2 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016