GW1--03881_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well.Contractor Information:
Spencer Adams 14.-WATER ZONES.
Well Contractor Name FROM TO I DESCREMON I
123 ft- 130 ft.
4449-A
(a0 ft. 40 ft.
NC Well Contractor Certification Number 3 -
Rowan Well Drilling FROM TO In1nAlETER L THICKNESS MATERIAL
Company Name 0 ft* 121 ft. in
6114 SDR21 PVC
13769 16.INNERCASING:0R, ING,*(eeatwi"l closed-loavl:.
2.Well Construction Permit#: FROM To I DIAMETER I T1HCK?4E&-; I-R—ATERiAL
list all applicable well construction perintis(e ux,County,state,vartance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: . . ....
3
FROM TO DUMETER I SLOTSUE I TMCJQqEsS I MATERIAL Agricultural [3Municipalftblic ft. A.
lGeothermal(Heating/Cooling Supply)
N,
E(Residential Water Supply(single) ft. ft. to-
Industrial/Commercial 13Residential Ifflater Supply(shared) A&GROUT -:'*
lbrigation FROM TO 51ATEXIAL EMPLACEMENT NIETHOD,&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- holeplug gravity 28 bags
Monitoring [3Rccovery ft. ft.
Injection Well:
% ft
Mo
nitoring
JAquifer Recharge Groundwater Remediation
�A%UWGRAVEL PAC fif a6plicabW 77777
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13SIormwater Drainage ft. ft.
perimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .10.'DR1LL1NqL0G-(uffaih tiddillon4l'shecU if necessary)
0 TO DESCRIPTION(color,hawnem sonlrock t"e,grain size,etc.)
Geothermal(Heating(Cooling Return) r3Othff.(explain under#21 Remarks) FROM
0 ft. 10 & clay
4.Date Well(s)Completed,5/19/23 Well IDN 13769 10 ft, 80 ft. sandy overburden
Sa.Well Location: so & ft. gravel/shale
Providence Management Ili (L 121 rL solid fuck
Facility/Owner Name Facility 1134(if applicable) 123 ft* % fracture
731 Miles Rd,Dallas 28034 ft. ft. intorwwtan rar;msec�iy hit
Physical Address,City,and Zip & ft.
Gaston 3539741655 1L RENIAPM.-.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Mong is sufficient) 22.Certification:
35 21.48.737 N 81 1325.658 W
6.Is(are)the well(s)opermanent or [:)Temporary Signature of Certified vVeR Contractor Date
By signing this form,I hereby cerdfy that the wells)was(o vre)constructed it)accordance
7.Is this a repair to an ej&tingwell: J3Ycs or ®No with 15A XC4C 02C.0100 or ISA lVC4C 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 ofilits record has been provided to the well owner.
repair tinder 921 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobeffiff 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 ofivells construction details. You may also attach additional pages if necessary.
drilled: SUBMnTA-L INSTRUCT
IONS
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 if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994 617
11.Borehole diameter 6 (in.) 24b.For Inketion 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,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test:weir 24c.For Water Supply&Injection Welk.-,In addition to sending the form to
chlorin 19 oz the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type:— e 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