GW1--00351_Well Construction - GW1_20240112

- IIPrint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES I , •
Well Contractor Name FROM TO DESCRIPTION
6 4449-A 38 ft. 425 ft. .029 GPM!
it. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Rcable)
Rowan Well Drilling FROM TO DIAMETERI THICKNESS MATERIAL
Company Name 0 ft 38 ft' 61/4 ;In' SDR21 PVC
327019 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.
ft3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
V Agricultural jMunicipal/Public 0 ft. H. in. i
N Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
D Industrial/Commercial DResidential Water Supply(shared) 18.GROUT „ - - --
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 Holeplug Gravity 8 bags
U Monitoring E3Recovery ft. fL
Injection Well: -
ft. ft.
l Aquifer Recharge U Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
*Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test 9Stormwater Drainage ft. ft.
II Experimental Technology DSubsidence Control ft ft.
Ir Geothermal(Closed Loop) jTracer 20.DRILLING LOG(attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSCRIP rlox(color,hardness eowroektype mkt s�etc)
0 ft. 20 ft. Clay
4.Date Well(s)Completed:8/24/23 Well In#327019 20 ft. 28 Sandy Overburden
5a.Well Location: 28 ft' 38_ s' Solid Rock
Madison Homes ft. ft. F-, :�f''�' -:< �' cl
Facility/OwnerName - _ - FactlityBM(if applicable)
ft. _ ft. -. ..• .-..�r. V
2755 Umberger Rd, Mt UlIa 28125 ft ft. JAN l 1 2024
Physical Address,City,and Zip ft. ft.
Rowan 554 038 21.REMARKs 1n:ziii::.-.i2.;:l r :=.,Ape.:.13 tits
DWQ)3c.4.a
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 42 17.490 N 80 44 40.531 W lz L 123
6.Is(are)the well(s)J%Permanent or Temporary �Signat�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: DYes or l2 No with ISA NCAC 02C.0100 or ISA 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 ar well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:425 (f) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) . 24b.For Injection 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,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-163 6
13a.Yield(gpm) .029 Method of test:24 hour 24c.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 20 OZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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