GW1-2022-09376_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 69 ft 290 ft. ,am
r
NC Well Contractor Certification Number 290 fL 305 ft- e con+
15.OUPER:CASING`(for muI"-cased wells'OR LINER if a livable
Rowan Well Drilling FROM TO DIAMETER TInCKNESS MATERIAL
Company Name 0 ft. 69 ft. 61/4 _._..in' SDR21 PVC
P Y
336665 16.INNER CASING OR TUBING the a]dosed-loon)
2.Well Construction Permit#: FROM ro DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. & in.
Industrial/Commercial DResidential Water Supply(shared) Ig,GROUT
Irri ation FROM TO ALITERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply WWI: 0 ft. 20 ft. holeplug gravity 31
Monitoring _ Recovery
Injection Well:
ft, ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
f Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL —PLACEMENT METHOD
C- Aquifer Test OStormwater Drainage
Experimental Technology .Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if neces§a'
Geothermal Heating(Cooling Return) r Other(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0 ft. 13 ft. red clay
4.Date Wells Completed:8/12/22 Well ID#336665 13 R. 6D ft.
() P sandy overburden
5a.Well Location: ft' 69 ft' solid rock
IQ Customs
Facility/Owner Name Facility ID9(ifapplicable) fL ft.
141 Brookleaf Lane, Mooresville 28115
ft.
Physical Address,City,and Zip ft. `7
Rowan 232AO93 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:
35 34 35.097 N 80 42 13.881 W 1 s•) t
6.Is(are)the well(s)oPermanent or Temporary 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: Oyes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the mature of the copy of this record has been provided to the well owner.
repair under 7:21 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
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
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwaier•levet is abovecasing,use"4-" 1617 Mail Service Center,Raleigh,INC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: 1n 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
13s.Yield(gpm) 20 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: 15 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