GW1-2022-00135_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTIOiV
4449-A
110 t. 120 fL
200 fL 240 ft. 45 GPM '
NC Well Contractor Certification Number 15.OUTER CASING foir lulti-eased welts OR LINER if a livable
Rowan Well Drilling FROM TO DIAMETER THICIavEss MATERIAL
0 It' 105 ft- 61/4l j in• SDR 21 PVC
Company Name 16.INNER CASING ORTUDING ®othermal closed-loop)
2.Well Construction Permit#: 376593 FROM To I DIAMETER I 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 fL in,
Water Supply Well: '•17.SCREEN:..
FROM TO DIAMETER SLOT SIZE I TH eMmSs MATERIAL
Agricultural [3Municipal/Public ft, ft. 'in.,
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft.
Industrial/Commercial. Residential Water Supply(shared) I-
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT htET110D&AMOUNT
Non-Water Supply Well: o ft, 20 ft. Holeplug, Gravity 28 bags
Monitoring Recovery ft. It.
Injection Well: ft. tL.
Aquifer Recharge Groundwater Remediation
MSAND/GRA►rEL PACK if a llcable
Aquifer Storage and Recovery OSalinityBaffier FROM TO MATERIAL Ehn?LACEMENT METHOD
Aquifer Test [3Stormlvater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach Additional sheets ifnecessa
Geothermal(Heatin Cooling Return) - Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soatrack type,grain size,etc.)
p ft. 20 [t. clay C
4.Date Wells Completed: 11/4/22 Well ID#376593 20 ft. go it.
() P Sandy overburden
5a.Well Location: w ft- 95 ft. weathered rock
9s 105 solid rock F1 c'
David Brinkley fL fr.
Facility/Owner Name Facility ID#(if applicable) 110 ft. 120 ft. soft rock
0 801 NC HWY, Mt Ulla tt tt. _
Physical Address,City,and Zip R. fr. {Iti;�iile r+jD� i::d•a Una
Rowan 558056 -2l.RENARKS- ✓: ; Of
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 4019.559 80 42 0.781 AJ-7�
6.Is(are)the well(s)Ox 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: E3Yes or [X No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
If this is a repair,fill out knomi well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form. i
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: 265 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
por multiple wetly list all depths if different(example-3@200'and 2@100) construction to the following: i
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 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of is 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 i cuter,Raleigh,NC 276994636
13a.Yield(gpm) 9 Method of test:Airlift 24c.For Water Sootily&Iniectioil Wells: In addition to sending the form to
the address(es) above, also subri»tl one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 12Oz 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 Resource) Revised 2.22r2016