GW1-2022-00134_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams Ia,wATERzoNs r
Well Contractor Name FRON1 TO I DESCRTMON
4449-A ss ft. 320 ft. A oust
320 ft 405 ft-
NC Well Contractor Certification Number 15:'UlJ1ERCASiNG"[oriunittasedwells'ORLINER'ifa"ticable ``
Rowan Well Drilling FROM I TO DL"WrER TffiCIINESS 51ATERUL
0 ft. 95 ft.
6114 1 in. SDR21 PVC
Company Name
373960 :16-INNERCASMG:URTMING eotheirmalclosed:Too
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.WC,County,State,Ya.►iance,etc) ft. % in.
3.Well Use(check well use): ft ft in.
175CREE1!I ..< .
Water Supply Well: "
FR01I TO I DIAMETER I SLOT SIZE TIHCKNESs MATERIAL
Agricultural [3MunicipallPublic ft. ft a.
Geothermal(Heating/Cooling Supply) Et Residential Water Supply(single) R. ft. is
Industrial/Commercial DResidential Water Supply(shared) _
Irrigation FROM TO MATERIAL E!HPLACnIENT METHOD&AMOUNT
Non-Water Supply Weil: 0 ft 20 R• Holeplug Gravity 27
Monitoring DRecovery it. ft.
Injection Well:
ft.
Aquifer Recharge 13Groundwater Remediation ft.
:'R7SAND/GRAVEI'PACK rfa lica6le
quifer Storage and Recovery Salinity Barrier FROaI TO DIATERM EMPLACEMENT METHOD
quifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft, ft.
Geothermal(Closed Loop) Tracer 20DRiLT,INCi'L06`etmeha'dditionalsheetsiifnecess
Geothermal(Heatin Coolin Return Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color hudness sofffmck in sae,etc.)
0 ft. 20 ft day
4.Date Wells Completed:11/21/22 Well ID#373960 20 ft. 70 tt. I
() p sandy overburden
5a.Well Location: 7D fa 85 ft' weawe�ed rack
Robert Hayes 85 ft. 95 ft. soNdrock _
Facility/Owner Name Facility]D#(if applicable) 96 it 122 R. soft green cock
11967 Hwy 801, Mt Ulla 28125 n• n• �� �`�
Physical Address,City,and Zip ft, ft. r v 1 t L
Rowan 558 054 2112E11fARKS sUri I
County Parcel Identification No.(PIN)
N
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,.one laillongis sufficient) 22. ertifieation:
35 40 21.200 N 80 41.57.766 N,
_ It (z i2Z
6.Is(are)the well(s)oX Permanent or 13Temporary Signature of Certified Well Contractor ,I Date
By signing this form,7 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or MNo with 15A NCAC.02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out!mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or an the back of thisform.
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: 405 (ft.) 24a..For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifd fferatt(example-3(200'and2®100) construction to the following:
10.Static water level below top of.casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.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
It Well construction method: 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) 5 Method of test: weir 24c.For Water Suoph&iniectil n;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: 1i Oz completion of well construction to,�tl a county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016