GW1--00057_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: "."
1.Well Contractor Information:
Spencer Adams
Well Contractor Name FROM TO DESCRIPTION
4449-A 55 ft 300 ft. Is 1
ft. ft. P
NC Welt Contractor Certification Number
Rowan Well Drilling MrrER 7A0mc'(rar�iD� eiis)oR TER THICKNESS
KNESS ip"u ATERIAL
Company Name p ft. SS ft 6114 1°• SDR 21 PVC
W 22 30 16 INNER CASING OR TUBING'(geothernrajetoseddloop) ,: ^ , _.
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.Stare•Variance,etc) ft. ft. ' ln.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17i,SGREEK ;':
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft, ft. in.
Industrial/Commercial9
OResidentiat Water Supply(shared)
`ri&'GROUT
Irrigation FROM ' TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr 20 fa Holeptug Grainy 8 bags
.i Monitoring Recovery ft. ft
Injection Well:
Aquifer Recharge Groundwater Remediation ft to
i
19iSANDlGRAVEL'PACIC fs hcnble)
quifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft ft i
Geothermal(Closed Loop) Tracer
O `.:20.,DRILLING:LOGieuterifidditiaoiilhhtbtiirueensarp) *
Geothermal(Heating/Cooling Return) (Other(explain under#2I Remarks) EOM To DESCRIPTION(wbq hardness,sotvreek type,pain size,etc.)
0 ft 15 ft.
Clay
4.Date Well(s)Completed:9/6/23 Well ID#W 22 30 75 iG 30 fr. t
Sandy Overburden
5a.Well Location: eo ff• 45 ft. Weathered Rock
Richard Goff 45 ft 55 ft Solid Rock
Facility/OwnerName Facility IDN(if applicable)
ft ft. ^.`"'. .•r, d `)jf-•i!
270 Pilgrim Ct, Lexington 27295 ft ft I �+ �-
Physical Address,City,and Zip ft ft. f L v 1tJ[3
Davidson 11323130000004A 21 REMARrts ::
County ParcelIdenfificationNo.(PIN) ' Intaf�4,= it:`"'.a,. ,y,e.P3 URA
J0 r.;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one tat/long is sufficient) 22.Certification:
35 51 46,380 N 80 12 33.034 W
�A-�,_� C9i 0 )23
6.Is(are)the well(s)OX Permanent or Temporary rgaahrre of Certified Well Contractor Date
By signing this form,I hereby certify that the uell(s)was(sere)constructed in accordance
7.Is this a repair to an existing well: OYes or }2 No with ISA NCAC 02C.0100 or ISA NCAC102C.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 Ate well owner.
repair under VI remarks section arm the back of 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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 1005
(B•) .24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list MI depths ifdeerent(example-3 a(200'and 2(l005 construction to the following:
f
10.Static water level below top of casing: (ft.) Division of Water Resources,'information Processing Unit,
Ifuater level Is above casing,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
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,detect push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
. FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) 1.5 Method of test:weir 24c.For Water Suonly&Infection 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 Chlorine 2.85 tbs
type. Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department o£Environmental Quality-Division of Water Resources Revised 2-22-2016