GW1-2022-10263_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well ConttactorNatne FROM TO DESCRIPTION
100 ft. 160 ft, 1.5 rpm
4449-A 260 ft. 305 ft. SGPM
NC Well Contractor Certification Number 15 OUPER'CASING'for mulh;iased vm6yOR:LMER`it:a`licable
Rowan Well Drilling FROM TO DIAMETER THICI WESS I MATERiAL
0 ft. 1 97 ft. 61/4 In' I SDR21 I PVC
Company Name
2021-00002062 :16:INNERCASINGtOR:. BING m"&the� ald6seil=ldo )
2.Well Construction Permit# FROM TO DLANIETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
1.176'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERL1r.
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) s::GROUT
Irrigation FROM TO MATERIAL £MPLACEhIEM1T METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holeplug Gravity 16
Monitoring CI Recovery ft. ft.
Injection Well:
fr. fr.
Aquifer Recharge Groundwater Remediation
14:-..SAND/GRAVEL;PACK if8 livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO .. MATERIAL MIPLACE51ENT 51ETHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed loop) Tracer 20.DRILLING LOG i attaeli additional sli&&R ifuecessa
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness saiVrock type,WAn sue,eta
0 ft. 15 ft Clay
4.Date Well(s)Completed:10/18/22 Well ID#202100002062 15 & 70 ft. Sandy Overburden
5a.Well Location: ra ft. 87 ft. weathered Rock
Phillip&Sara Stephenson 67 ft. 97 ft. Solid Rock °
Facility/Owner Name Facility ID#(if applicable) ft. ft. N O V 1 A 2022
3089 NC 134,Asheboro 27205 ft. ft.
Physical Address,City,and Zip ft. ft. ��
Randolph 7657570209 2L REINMRKS
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. ertification:
35 36 30.317 N 70 49 27,554 ar ���
6.Is(are)the well(s)�X Permanent or Temporary Signature of 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: [}Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
If his is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to lite well owner.
repair underV1 remarks section or on fire back ofthisform. 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (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:25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 243
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(Le.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 Suably&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: 14 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