GW1--00361_Well Construction - GW1_20240112

Print Form: :
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only �� s
1.Well Contractor Information:
Spencer Adams 14WATERZONi;
. 3
Well Contractor Name FROM TO i DESCRIPTION
4449 A 300 rt. 400 3 GPM
NC Well Contractor Certification Number 430 460 ft. 40 GPM
1S OUTER CASING(for multi-cased rosins)oR LINER Of so Ruble)
Rowan Well Drilling FROM TO . DIAMETER ,HICKNEss MATERIAL
Company Name q 0120 61/4 SDR21 PVC
2a7�192 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO ; DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC Corm%State,Variance.etc.) ft. ft. I,in.
3.Well Use(check well use): ft. I ft, i in.
Water Supply Well: •17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipauPub)ic 0 ft, ft, to.
Geothermal(Heating/Cooling Supply) X)Residential Water Supply(single) ft, it in
a Industrial/Commercial DResidential Water Supply(shared) 18.GROUT i
Irrigation .
FROM TO I MATERIAL EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: - 0 ft, 20 i ft. Holeplug Gravity 8 bags
Monitoring I Recovery 1L i ft.
Injection Well:
ff. s rt.
Aquifer Recharge DGropndwater Remediation 19.SAiND/GRAVE7i PACK dispensable)
Aquifer Storage and Recovery D5alinity Barrier FROM To ; MATERIAL Et►fPLACEMENTMEIISOD
Aquifer Test DStomiwater Drainage ft. it.
Experimental Technology DSubsidence Control tit 4 It,
()Geothermal(Closed Loop) DTracer 20.DRII.LING LOG(attach addidonal,beah if necessary)
QGeothermal(Heating/Cooling Return) ',Other(explain under#21 Remarks) FROM TO DESCRIPTION(eotor,dudeeee eoiltrocictype,grain du.etc)
0 it• 20 i Clay
4.Date wells)Completed:1 217/23 Well ID#23-192 20 ft. 100 t• Sandy Overburden.
Sn.Well Location: 100 ft 110> ' Weathered Rock
Caruso Homes 110 n 120 i ft. Solid Rock
Facility/Owner Name Facility MP(if applicable)
1020 Three Lakes Trl, Waxhaw 28173 ft. ;77 i NY %
Physical Address,City,and rip ' it JA N I u 7074
Union 05 075 0020 21.REMARKS ;``
County Parcel Identification No.(PIN) tr{�Y:{c.`3 n�r�r�j Q (;F'/i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v �'
await field,one 1at/long is sufficient) 22.Certification:
on:50 27.325 N 80 42 38.037 W /LQ-4.--
6.Wane)the wefi(s)4Permanent or DTemporary Signature of Certified Well Contractor I Date
I
By signing this form thereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or XDNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and etplain the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks section or on the back of thisform. 23,Site diagram or additional well dt tails:
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-I 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:465 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and2(0100') construction to the following: I
10.Static water level below top of casing:20 (ft) Division of Water Resources,Information Processing Unit,
!fattier level is above.casiny.use'+~ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (tn.) 24b.For Infection Wells: In addition sending the form to the address in 24a
rota above,also submit one copy of this form within 30 days of completion of well
ILWell construction method: ry construction to the following:
(i.e.auger,may,cable,diruetpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636111ail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)40+ Method of test Airlift 24c.Par Water Sanely&Infection Wells: In addition to sending the form to
Chlorine 21 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 ofWaterResources Revised 2-22-2016