GW1--03851_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER7ANES.
Well Contractor Name FROM TO DESCRIPTION
4449-A 100 ft. 200 ft. 2 cwa
370 R no ft, a GPM
NC Well Contractor Certification Number
Y5:"OUTER CASING for tmnlel-raied wells OR IIlVER if
Rowan Well Drilling FROM TO DIAME Elf :y THICKNESS MATERIAL
Company Name
0 61 it 61/4 in SOR21 PVC
10013523 'I6 INNER:CASYNGottTusING '€athernmiklosed low
2.Well Construction Permit#: FROM To I DiAMLTER I THICKN M I nIAT'ERUL
List all applicable well constnrctionpermits(i.e.WC,County,Slate,Variance,etc.) ft. ft. I I in.
3.Well Use(check well use): fa ft. in.
Hater Supply Well: 17'sCREEPi _
FROM TO 1.DIAMETER SLOTSIZE TMCi NM MATERIAL.
Agricultural [3Mtmicipal/Public ft. ft.
t in
Geothermal(Heating/CoolingSupply) Residential Water Supply(single) fi, in.
Industrial/Commercial Residential Water Supply(shared) 48,GROUT
Irrigation FROM To MATERIAL EWLACEMENTMUMOD&AMOUNT
Non-Water Supply Well: 0 ft 20 % Holeplug Gravity 14 bags
Monitoring Recovery ft %
Injection Wen:
fG ff.
Aquifer Recharge DGroundwater Remediation
19,t3ANl)lGRAVEti PACK-0 f i i hcable f.:: '
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL. fl4rPLACFHEIVT METHOD
Test DStormwater Drainage ft. fc
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20 )111"G'L'OG=attathiidditionstl ffneeess
FROM TO DPSCR�TION color,bard solOroels sae,e(G)
Geofhemtal(tleatin Coolin Return) Other(explain under#21 Remarks 0 fG 12 ft. r, .-�.
day r�5�.J a'°'R• .�.,
4.Date Weil(s)Completed:5/17/23 Well ID#10013523 12 ft. 40 ft. day sandy y
Sa.Well Location: W ft. so ft. sandy overburden J U N
Pat Benfield so ft- 71 fe weathered rods _
Facility/Owner Name Facility lDll(ifapplicable) 71 iL as it sand rode
11027 Windy Grove Rd,Charlotte 28208 82 fr. 90 ft frvis rock isharp
Physical Address;City,and Zip 165 it, 200 it• large fractures
Mecklenburg 113 251 09 21 REltifAWC8,'
County Parcel.Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3512 35.419 N 80 59 49.940 a,
� J� t<L3
6.Is(are)the well(s)O%Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify that the weil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or XINo with 1SA NCAC 02C.0100 or 15A NCAC 01C.0200 iPell Construction Standards and that a
Ifthis is a repair.fill out knmvn well construction information and explain the nature ofthe copy ofthis record has been provided to the xell owner.
repair under 421 remarkr section or on the back ofthis 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-1 is needed. Indicate TOTAL NUMBER of%vells construction details. You may also attach additional pages if necessary.
Wiled'I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ird ferent(example,3@200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources;Information Processing Unit,
guater level is above casing,use"r" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Injection Wells: In additiowto 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) 10 Method of test: atri1R 24c.For Water Supply&Iniection 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: 19oz completion of well construction to the:county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016