GW1--00321_Well Construction - GW1_20240112

Print Form -I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams .14.WATER ZONES I, '
FROM TO DESCRIPTION
Well Contractor Name
120 125 ft- 2 GPM
4449-A 310 n 325 ft- 9 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased Wells)OR LINER(if ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 77 ft• 61/4 in. SDR21 IPVC'
Company Name 2023-35522 16.INNER CASING OR TUBING(geothermal closed-loop)_
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC County,State,Variance,etc.) ft ft• ; id
3.Well Use(check well use): ft.
17.SCREEN.- ,, ,
Supply Well:Water FROM TO DIAMETER ��SLOT SIZE THICKNESS MATERUII.
Agricultural °Municipal/Public 0 ft. ft. In.
Geothermal(Heating/Cooling Supply) X°Residential Water Supply(single) it. ft in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Holeplug Gravity 8 bags
Monitoring ()Recovery ft. R.
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft. i
Experimental Technology °Subsidence Control ft. ft. j
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,hairnets soalrocktype grain�,etc)
0 n 20 ft• Red Clay
4.Date Well(s)Completed:12/15/23 Well ID#202335522 20 it. 67 SandylOverburden
5a.Well Location: 67 f' 77 ft' Solid Rock
It Builds 95 it 109 ffi Brown kocip 77, p"----r Is ,�,,
Facility/Owner Name FaciityID#(if applicable) ft ft. E D
198 Austin Rd, Statesville 28625 ft. ft. JAN 1 %, 202A
Physical Address,City,and Zip ft
Iredell 4736 46 6036 21.REMARKS ,.info~ - `or.11 Pr^,t :b1.” l'e
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !,
(if well field,one lat/long is sufficient) 22.Certification:
35 50 23.122 N 80 54 31.448 W i.LA is-In
6.Is(are)the well(s)0Permanent or Temporary rgoatn 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: JYes or InNo with 15A NCAC 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.
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:1 SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 345 (ft.) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdffferent(example-3@200'and 2@100') construction to the following: ,
10.Static water level below top of casing:30 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Marl 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) 11 Method of test:weir 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
chlorine 16 OZ completion of well construction to the countyhealth department of the
13b.Disinfection type: Amount: mP eP county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016