_Well Construction - GW1_20230320 (76)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �?
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 48 ft. 110 ft, 3rPM
220 ft' 265 ft. r crM
NC Well Contractor Certification Number 15.OUTER EASING for multi-cased wells OR LINER(if up lieable
Rowan Well Drilling FROM TO I DIAMETER THICKNESS I MATERIAL
Company Name
ft. 48 ft. 6114 in- SDR21 PVC
'
2022000040 16.INNER CASING OR TUBINGIReothermal dosed400
2.Well Construction Permit#: FROM TO DIAMETER I TRCKNTSS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :17;SCREEN
FROM TO DIAMETER SL.OTSIZE I THICKNESS I NrATERIAL
Agricultural QMunicipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft: [t: in
lndustriaUCommercial [DResidential Water Supply(shared) 18.GROUP
h71 ation FROM TO MATERIAL. EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply We11: o ft. 20 ft. Holeplug. Gravity 8
Monitoring Recovery ft.. ft.
Injection Well: .
Aquifer Recharge OGroundwatcr Remediation 19:SAND/GRAVEL PACK fifanulicablel
Aquifer Storage and Recovery Salinity Barrier FROM TO 1%1ATERLAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft.. ft.
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if neemsa
Geothermal(Heating(Coolin Return) 00ther(explain under#21 Remarks) 1
FROM TO DESCRIPTION colon hardness,soil/rock in ske,etc
0 ft. 18 ft, Clay,t Shale
4.Date Wells Completed:219/23 Well ID#2022000040 1e ft. 48 .
P ft. d Rock
Sa.WeIi Location:
ft. ft.
Otey Construction ft. ft.
Facility/Owner Name Facility ID/1(if applicable) ft. ft.
1876 Rocky Cove Lane, Denton ft.
Physical Address,City,and Zip ft. ft.
Davidson 2L REMARKS . MAR n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Cif'
(if well field,one latnong is sufficient) 22.Certification•
35 36 52.401 N 80 13 19.628 W
6.Is(are)the well(s)E)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: QYes or E)No with 15A NCAC 02C.0100 or ISA 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 921 remarks section or on the back ofthisform.
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 (fL) 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: 10 (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc_) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Weir 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
136.Disinfection type: Chlorine Amount: 12 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