GW1-2023-02603_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams M�WATER-ZONES . -,,_'
Well Contractor Name FROM TO -DESCRU'In'ON
200 fL 265 fL 7 GPM
4449A
ft. ft.
NC Well Contractor Certification Number
,45.1:,OUTEWCASING for multucaseil'.,ivellsy
FROM TO I DIAMETER THICKNESS I MATERIAL
Rowan Well Drilling OF
0 ft- 60 ft- 6 1/4 ' i-- I SDR21 G.lv
Company Name
" .'­16-INNERCASING-0 - BING'(�*eothiritial-doie�d=lbob) l�--- .-,,
2.Well Construction Permit#: 312001 FROM TO DIAMETER. THICKNESS P 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.
'A. �44
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural E]Municipal/Public ft. ft. in.
'lGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft.
:11ndustrial/Commercial [3Residential Water Supply(shared) ;,18.GROUT,-.-;, vll­;,,=
lIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 73
DMonitoring CiRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation
'19.3AND/GRAVXL PACK ffi6p livable
)�-,'
3Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3Aquifer Test DStormwater Drainage ft. ft.
_lExperimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) []Tracer 120 DRILLINGLOG*(ittiichadditio-na'l,'sb6etsifjie;tessA' -'.-
E:Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type in size,etc.)
0 ft. 20 ft- Clay
4.Date Wells)Completed:3/1/23 Well ID#312001 20 ft. 40 ft. Sandy Overburden
5a.Well Location: 40 ft. 50 ft. Weathered Rock
Cornerstone III Properties 50 ft. 60 ft* Solid Rock
Facility/Owner Name Facility D:)#(if applicable) ft. ft.
132 Lippard Springs Circle, Statesville ft. ft. -j-",
Physical Address,City,and Zip ft. ft. APH 1 0
fredell 4722670141 _21 REMARK&`,'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22
35 43 57.575 _N 80 56 2.511 W 3 It J23
6.Is(are)the well(s)OPermanent or [3Temporary 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: E3Yes or nxNo 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 an 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 I 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 00 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:20 00 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 27699-1636
13a.Yield(gpm) 7 Method of test:weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 12 oz the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction. to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016