GW1--03239_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Weil Contractor Information:
Spencer Adams I4.WATER`ZONEs
FROM TO DESCRIMON
Well ContractorName 77 ft. 500
4449 A ft. ft.
NC Well Contractor Certification Number 1&.OUTER'CASING focmultt-easedwells"OR:LINER ifB Ucsble
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 77 ft- 61M in- SDR21 PVC
Company Name 16 INNER,CASING OR:TUBING"eathermal diiwil-lo6
2.Well Construction Permit#:WELL 09 2022 179650 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft.
3.Well Use(check well use):
'17cSGREEI\-
Water Supply Well: FROM TO i DIAMETER I SLOT SIZE I THICENT.SS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
Industriavcommercial EIResidential Water Supply(shared) IS:iGROUT`
X Irri ation FROM TO MATERIAL EniPLACEMENTWTHOD&AMOUNT
Non Water Supply Well:. 0 ft. 20 ft. Holeplug Gravity a bags
Monitoring [;Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
49 SAND/GRAVEL PACK if a''licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology oSubsidence Control
Geothermal(Closed Loop) OTracer `20.VRILLINGLOG amicti addtNonalsheets'ifnecessa
FROMTO DESCRIPTION rotor hardness,sofVrocli m size etc.
Geothermal eating/Coolin Return) Other(explain under#21 Remarks) 0 ft. 20 ft- Clay
4.Date Wells)Completed:4/5/23 Well ID#092022179650 20 ft. 50 ft• sandy overburden
5a.Well Location: W f` 67 ft. Weathered Rock
-George Verhoest 67 ft. 77 I'L Solid Rock
Facility/Owner Name Facility IDY(if applicable) 265 ft. 3W h' Broke Into otheawellve n•fIN
2889 Mt Pleasant Rd, Sherrills Ford ft. f` '¢`" a
2023
Physical Address,City,and Zip ft. ft MAY 1 1
2I:xEtifARxs;
Catawba 460803137925 >
If t tv l 17
r•tr'ws"Sur
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 Certification:
35 36 45.808 N 81041.044 �, ./c- `"-'✓ , `f 1 3
6.Is(are)the well(s)oPermanent or Temporary
Signature of Certified Well 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 x JNo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0100)Yell Construction Standards and that a
If this is a repair,fill out known well construction Infornunion and explain the nature of the copy of this retard has been provided to the well owner.
repair under k21 remarks section or on the back of thisform. 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: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiple wells list all depths#different(example-3 a200'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:
(Le.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) 1 Method of test:weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addregs(es) above, also submit one copy of this form within 30 days of
Chlorine Amount: 1.6Ibs completion of well construction.to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016