GW1-2023-02607_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRWTWN
4449-A 84 ft- 325 ft,
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASINO for multi eased WeM)12R LINER_ifagpliablel
TMCJ
Rowan Well Drilling ��TO DIAMETER MATERIAL
0 ft- 1 84 ft. 6114 in. I SDR21 PVC
Company Name 16.INNER CASING OR-TUBIXG"(ae6thiiiiial,d6sid-166�).-.
2..Well Construction Permit#: EHW22-04548 FROM --- TO DIAMETER I THICKNESS I MATERIAL
List all applicable well constilictumperimis ri e.UIC,County,Stale,Variance,etc) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
: .-,
Water Supply Well; M SCREEN
FROM TO I DMAIETER I SLOTSIZE I THICKNESS I MATERIAL
—JAgricultural [3Municipal/Public ft. ft. in.
_lGeothermal(Heating/Cooling Supply) .Residential Water Supply(single)
:11ndustrial/Conuncrcial Residential Water Supply(shared) ft. ± in
L .
.18.GROUT:::�
Ifixigation FROAT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 & 20 ft. Holeplug Gravity
:]Monitoring [3Recovery ft. ft.
Injection Well: ft. ft.
Ieothermal
quifer Recharge E)Groundwater Remediation
19 SAND/GRAY UL PACK
fifilipli6bley. 1.-' .� AC
Aquifer Storage and Recovery Salinity Barrier FROM TO AUTERIAL_ EMPLACEMENT-NIETROD
quifer Test DStormwater Drainage ft. ft.
xperimental Technology nSubsidence Control ft. ft.
eothermal(Closed Loop) ElTracer
FROA1 TO DESCRIPTION(color,hardness.soil/mck type,grain size,etc.)
(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 20 ft. clay
4.Date Well(s)Completed.3122/23 'Weil ID#EHW2204548 20 ft- 40 ft.
Sandy Overburden
5a.Well Location: 40 ft. 74 ft. WeatheredRock
Sabrina Gregory 74 ft. 84 ft- Solid Rock
Facility/Owner Name Facility 1139(if applicable) ft. ft.
15 Knotty Wood Lane, Vale ft. ft.
Physical Address,City,and Zip ft. ft. APR
�11. 71�
Lincoln 10879
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35 31 12.612 N, ZE; 41,-U I
s
6.1s(are)the well(s)oPermanent or DTemporary Signature bfCcrtified 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: [3Yes or Wo willo 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards mid 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 lite well owner.
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
S.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-I is needed. Indicate TOTAL NUMBER ofvvells construction details. You may also attach additional pages ifnecessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 00 24a. For All Wells Submit this form within 30 days of Completion of well
For multiple wells list all depths ifdifferenl(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,
lfwater level is above casing.use"+" 1617 Mail Service'Center,Raleigh,NC 276994617
11.Borehole diameter: 6 —00 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:
(Le,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undergrouud Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: weir 24c.For Water Supply&Inic tin 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: 15oz completion of well construction 1tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-222016