GW1--08027_Well Construction - GW1_20231214

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 290 ft. 300 ft• 25 GPM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Rowan Well Drilling FROM TO DIAMETER t THICKNESS MATERIAL
0 85 ft. 61/4 is SDR21 IPVC
2.CompanWell Name 2U23-1 S22�1 16.INNER CASING OR TUBING(geothermal closed-loop)
Well Construction Permit#: LJ SILL FROM TO DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State Variance,etc.) ft.
3,Well Use(check well use): ft ft. 1°'
•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgrieultutal QMunicipallPublic 0 ft, ft. in. ,
Geothermal(Heating/Cooling Supply) "xOResidential Water Supply(single) R. ft. In. ,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL .EMPLACE.MENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 ft. Holeplug Gravity 8 bags
°Monitoring °Recovery iL ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediatioa 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery QSalinityBarrier FROM TO MATERIAL : EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft. j
Experimental Technology OSubsidence Control ft. ft. j
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) PROM TO ' DESCRIPTION(color,baldness,Wilcock type,grin ela,etc)
11/6/23 2023-15221 0
25 Clay i` .
4.Date Well(s)Completed: Well ID# 25 75 Sandy Overburden
5a.WellLocation: 75 R 85 ft' Solid Rock
Cline.Custom Homes 92 it 94 ft. Brown Rock Layer
Facility/OwnerName FacilityTD#(if applicable) 1O0 ft. 103 iL Brown Rock Layer
117 Beacon Ridge Dr, Stony Point 28678 ft, ft. :..
Physical Address,city,and zip ft Ir. l �, ; '2
A
Iredell 3774 62 3986 21.REMARK r�
County Parcel Identification No.(PIN) LP—( �Ut!
Sb.Latitude and longitude in degrees/minntes/seconds or decimal degrees: ..r.;�::^::``"^. 7'^^cs`Ar.,r: LiSI
(ifwell field,one lat/long is sufficient) 22,Certification: CL v C1'3 Jb3
35 46 24.692 N 81 6 7.322 WAS_____ 1 t I k 123
6.Is(are)the well(s)4)Permanent or QTempora Signature of Certified Well Contractor Date
r'
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or X)No with ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
!Phis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the reel!owner.
repair under tel remarks section or on the backof this 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 TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface:325 •
(f0) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q101Y) construction to the following:
10.Static water level below top of casing:40 (IL) Division of Water Resources,Information Processing Unit,
If aster level is above Casin&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:
(ie.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)25 Method of test:weir 24c.For Water Sunray&Injection 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: 19 OZ 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 Revised 2-22-2016