GW1-2022-10316_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.WeR Contractor Information:
Spencer Adams MWATEIRZONES
Well Contractor Name FROM_ TO DESCRIPTION
4449-A 103 ft- 125 ft, 1.5 GPM
245 ft. 285 ft. ,GPM
NC Well Contractor Certification Number J&OUTER CAStNG.(for-&ulfilcagid welts l.MLMER ifapVcable)��
Rowan Well Drilling FROM I TO ft. I DIAMETER THICKNESS
MATERIAL
Company Name
0 ft. 1 97 6114 in. I SDR21 PVC
4C INNER'CAS1,NG:OR TUBING(keothermalclbsed-loop)'
2.Well Construction Permit#:2022071 FROM TO DIAMETER I THICKNESS MATERIAL.
List all applicable well construction permits(i.e.WC.County,State,Valiance,etc.) ft• ft. in. I
3.Well Use(check well use): fL ft. in.
17;SCREM
Water Supply Well;
FROM — TO DIAMETER SLOT SUE THICKNESS- MATERIAL
Agricultural OMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) iResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
GROUT
Irrigation FROM - TO MATERIAL EMPLACEMENT IkEETHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 18
DMonitoring E3Recovery ft. ft.
Injection Well: ft. ft.
I Aquifer Recharge 0Groundwater Rernediation 2.19.SAND/GRAVEL-PACK.if aiinticAt)leI
3Aquifer Storage and Recovery :Salinity Barrier
FROM TO I MATERIAL I EMPLACEMENTAIETHOD
D. Aquifer Test OStormwater Drainage ft. it.
'lExperimental Technology OSubsidence Control ft. ft.
RGeothermal(Closed Loop) [3Tracer -20.',DRILL G'.LOG,(rittachiidditiatial:sh-e-etsift6te3s'ni'y
Geothermal(HeatingiCooling Return) MOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,saWrock type,grain sg�etc.)
0 ft. in ft- clay
4.Date Well(s)Completed: 10/14/22 Well ID#2022071 10 ft. 68 ft. Sandy Overburden
5a.Well.Location: 6a It- 87 ft. Weathered Rock
Chuck Edwards Inc 87 ft. 97 ft- Solid Rock
Facility/Owner Name Facility,MM(if applicable) 103 ft- 110 ft. Soft Vein RECHN/pr�
0 Hastings Rd, Kernersville 27284 114ft' 120 "" Soft vein — �q V &—%—f
Physical Address,City,and Zip ft. ft. NUV 1 4 2022
Forsyth
.7
ln4orVna�10qi k'rx3af-xT,,J Ung
County Parcel Identification No.(PIN) Q-G-
5b.Latitude and longitude in degrees/minutestseconds or decimal.degrees:
(if well field,one hit/long is sufficient) 22.Certification:
3629.720 N 80659.427 W
6.Is(are)the welf(s)OPermanent or E3Temporary 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: [Dyes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid dial a
If this is a repair,fill out known Well COnStrUC110t)m1a"Mi7tiOn and explaili Cite nature Of lite copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of ibis 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 286 (It-) 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.40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6 —(in.) 24b.For Infection 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) 9 Method of test:Airlift 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: 13 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