GW1-2022-00187_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams a4 WATER zoNEs
Well Contractor Name
FROM TO DESCRIPTION
4449-A �,,a 4= c �!m� 370 rt. 400 ft. 75 GPM
ft. ft.
NC Well Contractor Certification Number D f C 1 3) 2022 15::0UTEk'CAS1NG`formulh caseHl'wells'OR I'INER`if a Gcable' "
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL -
p ft. 85 ft. 61/4 I in sd21 PVC
Company Name r:�`>=);�ti:
32$$ $ 16AINNERCASING OR`TUBING``eotliermal-ctosed4do .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LUC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •=17.SCREEN r
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. I ft. I in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft. in.
Industrial/Commercial QResidential Water Supply(shared)
hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. holeplug gravity 13 bags
Monitoring CIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
.r19 SAND/GRAVEL PACK if a' livable°_
Aquifer Storage and Recovery MSafinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ~
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -'20:DRILEINGrtiOG attach;additioiial sheets if uecesss'
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock in size,etc
0 ft. 18 ft. clay
4.Date Well(s)Completed: 11/23/22 spell ID#328818 16 ft- 70 ft• sandy overburden
5a.Well Location: 70 ft. 75 ft' weathered rock
Ricky Martin 75 ft. 66 ft* solid rook
Facility/Owner Name Facility ID#(if applicable) fL fL
1976 Charlotte Hwy, Mooresville 28115 ft. ft.
Physical Address,City,and Zip ft• ft.
i
Iredell 4658 77 3386 z1 xENrARKs`':`
County Parcel Identification No.(PN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22, ertitieation:
35 37 29.371 80 49 34.741
N W
6.Is(are)the well(s)oPermanent or JDTcmporary Signature of Certified Well Contractor I 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 )No 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 this form.
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 if different(example-3@200'and 2@I00) 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 27699-1617
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 thislform within 30 days of completion of well
12.Well construction method: construction to the following: I`
(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) 25 Method of test: Weir 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: 19°Z 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