_Well Construction - GW1_20230320 (81)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams
p "14::WATER=TONES
WellContractorName FROM TO DESCRIPTION
4449-A 200 ft- 300 ft' larpm
ft. fc
NC Well Contractor Certification Number
15'OUTER CASING`for'multi cased',well§'OR LINER''it a"'livable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 1 100 ft' 61/4 1n' SDR21 PVC
Company Name `16INNERCASING`OR`TUBING "'eotherinatclosed=lo'o
2.Well Construction Permit#:WELL-10-2021-158832 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. ft. in.
1:7
Water Supply Well: :SCREEN.,�.
FROM TO SDIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMumicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) g• ft. in.
Industrial/Commercial Residential Water Supply(shared)
A8 GROUT',
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft. Holeplug Gravity 8 bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation ,19:SAND/GRAVEL-PACK if a'livable
I_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
BGeothermal(Closed Loop) Tracer 20:DRILLING`LOG•attach.additidn'al'sheets if uecessa "
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIMON color,hardness,soiltrock in size,etc
p ft. 15 ft. Clay
4.Date Well(s)Completed:2/24/23 Well ID#102021158832 15 ft. so ft. Sandy Overburden
5a.Well Location: ea ft. 90 ft. Weathered Rock
Cornerstone 3 Properties so ft, 100 ft, Solid Rock
Facility/Owner Name Facility ID#(if applicable) 120 ft, 130 fG
8157 Long Island Rd, Catawba 150 ft 160 ft. Brown vein
Physical Address,City,and Zip ft, ft.
Catawba 470002970337 r-REMARKS,:"" . 5 .
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 5E "'
(if well field,one lat/long is sufficient) 22.Certification:
35 40 37.653 N 80 59 23.924 W
6.Is(are)the well(s)IX Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certij�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EbNo 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-I 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 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if drfferent(example-3t200'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 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 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 10 Method of test: Weir 24c.For Water Surmly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: 14 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 i Revised 2-22-2016