GW1--03266_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD(GW-I)
r Internal use Only:
1.Well Contractor Information:
Spencer Adams
14::9VATER ZONES.:
7.7
Well Contractor Name
FROM TO DESCPIM N
4449-A 105 ft. 165 ft, is CPM
NC Well Contractor Certification Number 340 it 380 ft" 3S GPM-
IS.,OUTER CAS1NG!'f.0r_-- ulfi�_
Rowan Well Drilling -I- cased1welb ORLINER'll'a
TO 2W �04_77 77=7
I IRM I I THI MATER4tL
Company Name 0 ft 98 ft. 6114 in.I SDR21 PVC
AP 317279 16.'INNER C-ASIN49 TUBING`
2.Well Construction Permit#: FROM TO DI4ifEfER THICKNESS MATERIAL
List all applicable'veil courtructionpernifts(1-e.UIC.County,Slate,Variance,etc) ft ft. in.
3.Well Use(check well use): fit. ft,
Water Sup ply Well:
Agricultural
o : FRttOM ft. TO
DIAMETER
SI
LOWSIZE
MATERIALuncpa/Public ft ft imGeothermal(Heating/Cooling Supply) IROSidential Water Supply(Single)
dsra/Corcil O ft. in
Residential Water Supply(shared) ' ,Irrgation 1S,.GRUT.­
FROM TO MATERIAL VE MMOO& UN:
TNon-Water Supply JVell: 0 ft- 20 ft
Monitorin
O Holeplug Gravity 19bags
IDJec"on Well: Recovery ft ft.
. Aquifer Recharge Groundwater Remediation ft. ft
19. VELPACK if. i�l1cb eAquifer
Storage and Recovery E3Salinity Barrier FROM TO MATERIAL
EMPLACTMENTMETHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer
_'20.DRILLI a
FROM
Geothermal(Heating/Cooling Return) -00ther(explain under*21 Remarks) -Xi- 51S grain shr-etc.)
0 ft 19 ft. tiny
--
4.Date Well(s)Completed:4/27/23 Well ID#AP317279 10 ft 70 ft. sappodite
Sa.Well Location: _10 % 88 %
weathered granite
t
Empire Homes 88 ft- 98 ft solid roc*
FacilitylOwnerName Facility lDfl(ifappli..bl.) ft. ft -_UAL
398 Templeton Rd, Mooresville ft. ft.
Physical Address,City,and Zip ft f
ft.,
fredell 4645181229 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcU fichL one lationg is sufficient) 22.C rtillcatilon:
353238.024 80 52 43.070
-W
6.Is(are)the well(s)OPermanent or OTemporary Signature ofCcrtified Well Contractor Date
By signing This form,I hereby cert6 that the wells)'vas(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or [RI No with 1JA NCAC 02C.0100 or ISA AVAC 02C.0200 Well Construction Standards mid that a
Ifthis is a repair,fill our knol m ire/i construction information and explain the nature ofthe copy ofthis record has been provided to lite irell on wen
rgpatr under#21 remarks section or on the back afthisform.
23.Site diagram or additional well details:
8.For GeoprobeAE)PT 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 ofwvll.s construction details. You may also attach additional pages,ifnecessary.
drilled:I
SUBMITTAL INSTRUCTIONS9.Total well depth below land surface:-605
Fortnulliple wells list all depths ifdifferent(example-3@ 200'and2@100') 249. For All Wells Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
Ifirater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ro (in.) 24b.For Injection Wells, In addition to sending the form to the address in 24a
12.Well construction method- rotary above,also submit one copy of this form within 30 days of completion of well
(i.e,auger,rotary,cable,direct push,.etc.) construction to the following-.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:weir 24c.For_WaterSui)vlv&Injection Wells; In addition to sending the form to
Chlorine the address(es) above, also submit one copy of this form within 30 days of
13h Disinfection type: Amount, 1.8 lbs 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 I Revised 2-22-2016