GW1--00037_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Todd Adams 14.WATER ZONES 4-
Well Contractor Name FROM 1O DESCRIPTION
2522-A 190 385 ft- 7 GPM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multl-casedwells) lic OR LINER(If ap able)
Rowan Well Drilling FROM TO DIAMETER ' THICKNESS MATERIAL
0 ft 120 ft- 61/4 In-, SDR21 PVC
Company Name 16971
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO ; DIAMETER ; THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. , in.
3.Well Use(check well use): ' ' in,
Water Supply WeD 17.SCREEN
FROM TO DIAMETER I SLOT SITS THICKNESS MATERIAL
Agricultural °Municipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigat1on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 m Bentonite Gravity 8
Monitoring °Recovery ft ft. .
Injection Well:
ft •
1� ft.
Aquifer Recharge DGroundwater Remediahon •
19.SAND/GRAVEL PACK Of applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer TestStomlwater Drainage ft. ft. I
Experimental Technology (°Subsidence Control ft. ft.
P '
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary).
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soll/rocktypy groin elie,etc)
0 n 95 ft. day
4.Date Well(s)Completed:9/29/23 Well ID#16971 95 n 115 ft brown quartz,granite
5a.Well Location: 119 ft- 180 brown med hard granite
Custom Remodeling Services 180 ft 405 ft' blue granite
Facility/Owner Name Facility ID#(if applicable) ftft.
122 Laura Rd Mooresville ft. g 'a. 4-'i
...
ft ft. S 1J n�3
Physical Address,City,and Zip
lredell 4658 53 6460 21.REMARKS OFF, 1
County Parcel Identification No.(PIN) '
Iilsvftt= i7:;!11 Cs';; , ;n. liP7h
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Sidi �..s``_'0'2
(if well field,one lat/long is sufficient) 22.Certification: '
35. 61422 N 80' 83144 WAt0--j-------1
°i 12a )23
6.Is(are)the well(s)J)Permanent or °Temporary Signature of Certified Well Contractor 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: 1111 Yes or x°No with I5ANCAC 02C.0100 or 15A NCAC 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. it
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 wells construction details. You may also attach additional pages if necessary.
drilled:t 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 tf different(example-3@200'and 2Qa 100') construction to the following:
10.Static water level below top of casing:36 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
I:
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
air drilling 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
i
13a.Yield(gpm)7 Method of test air 24c.For Water Sum&iv&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
136.Disinfection type:Chlorine Amount: 21 OZ completion of well construction to the county health department of the county
where constructed. I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016