_Well Construction - GW1_20230320 (80)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.well Contractor Information:
i
Spencer Adams la WATER ZONES k ',
FROM TO DESCRIMON
Well Contractor Name 62 ft. 165 ft. 7 GPM
4449-A ft. fr.
NC Well Contractor Certification Number
.TS.OUTER CASING'f6eniulti-cascdsvells'-0R`LINERi if a'"tic8ble
Rowan Well Drilling FRont To DIAMETER THICKNESS AIATERIAI
0 ft- 1 62 ft- 6114 in' I SDR21 PVC
Company Name
16sINNERCASING10RTUBING eotheruial`cI:—loo
WELL-03-2022-167136 FRo11 I To I DIAMETER THICKNESSI MATERIAL
2.well Construction Permit#:
ft. in.
List all applicable well construction permits(t.e.b7C,County,State,Variance,etc.)
ft.
fr. ft. in.3.Well Use(check well use):
17r'SCREEN.
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICtavFSs MATERIAL
Agricultural QMunicipal/Public ft. ft. i�•
Geothermal(Heating/CoolingSupply) X)Residential Water Supply(single) ft, ft. ►n.
Industrial/Commercial Residential Water Supply(shared)
IS.GROUT a,..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• Holeplug Gravity 30 bags
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
,Aquifer Recharge Groundwater Remediation -
19.SAND/GRAVEL PACK`da' livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT atr;rHOD
Aquifer Test E)Stormwater Drainage fr. ft.
4
Experimental Technology Subsidence Control fr. ft.
Geothermal(Closed Loop)
Tracer 20 DRILliING:L06'attach'sdditiouslsheetsifnecessa"'
FROM I TO DESCRIPTION color,hardness.sorVrock type,itrain simeta `
Geothermal(HeatingfCooling Return) nOther(explain under#21 Remarks) I o g, 15 ft• clay t sand
4.Date Well(s)Completed:2/22128 well ID#032022167136 15 ft. 20 ft• Gravel/Clay
m ft. 48 ft. Sandy overburden
5a.Well Location:
Empire Homes 46 ft• 62 ft, Solid Rock
FacilitylOumerName Facility ID#(if applicable)a 69 ft' r< ft* Brown vain/water
3768 Dockside Lane, Sherrills Ford 28658 92 ft' 100 ft. Brown vein
Physical Address,City,and Zip 245 ft. 300 ft, multiple veln¢•Iwater^
Catawba 460701457350 '21 REMARKS
ki
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22 ertifieation: ""''' � .e Clues
35 35 21.200 N 8107.635 W Z-1 Z -1 Z3
ignatur of Certified Well Contractor Date
6.Is(are)the well(s)E)Permanent or OTemporary
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or xINo with I5A NCAC 02C,0100 or 15A NCAC 02C.0200!Veil Construction Standards and that a
If this is a repair,fill out!mown well construction information and explain the nature of file copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis form. 23•Site diagram or additional well details:
S.For Geoprobet.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 OW-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: 305 (ft.) 24a. For Ail 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: (ft.) Division of Water Resources,Information Processing Unit,
Ifwaier 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 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;flail Service Center,Raleigh,NC 27699-1636
Method of test:weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) 3 - the address(es) above, also submit one copy of this form within 30 days of
Chlorine Amount: 15 oz completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc s
Revised 2-22-2016