GW1-2022-00142_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 DESCRIPTION
180 ft. 245 ft. 4GPM1
4449-A i
ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi-ased wells OR LINER it a licable
Rowan Well Drilling FROM TO DIAMETER TffiCKNESS MATERIAL
0 ft. 80 ft. 6 1/4 in SDR 21 PVC
Company Name
328515 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. M in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ©Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holeplug Gravity 18 bags
Monitoring CIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 3 Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRRMON color,hnrdnes soiltrock e, in ske,elc
Geothermal(IIeating(Cooling Return) Other(explain under#21 Remarks) o M 20 ft. Gay
11/3/22 328515 ft. ft.
4.Date Well(s)Completed: Well lD# 20 75 Sandy overburden
$a.Well Location: rs ft• 85 ft solid rock
Frances Banks 91 ft. 94 fL soft rock F 7
Facility/Owner Name Facility ID#(if applicable) ft. ft.
0 Townville Dr, Kannapolis 28081
Physical Address,City,and Zip & fL
Rowan 249EO94 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 30 36.643 N 80 39 18.681 W
6.Is(are)the well(s)E)Permanent or 13Temporary Signature of Certified well Contractor Date
By signing this form,I hereby certif�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known 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 on 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: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if doereni(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
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
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) 4 Method of test:Airlift 24c.For Water Supply&Iniel ti n Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine , 12 oz completion of well construction)to the corm health department of the county
136.Disinfection type: Amount. P � county P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016