GW1--01031_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
4449-A 50 ft 450 ft 1/2 GPM -
th o ft 14-7© ft' 20 GPM J
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 ft. 50 ft. 6 1/4 1'in' SDR21 PVC
Company Name
353848 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,eta) ft ft. ' in-
3.Well Use(check well use): ft. ft.
Water Supply Well: FR SCREEN DIAMETER 4 SLOT SIZE THICKNESS MATERIAL
Agricultural R Municipal/Public 0 ft ft. In.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial DIResidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Holeplug Gravity 10
Monitoring IDRecovery ft B.
Injection Well: ft ft.
Aquifer Recharge Di Groundwater Remediation ' .
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft ft.
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,hudaess mll/rocktypc,man she,etc.)
0 ft 18 ft Clay
4.Date Welke)Completed:1/26/24 Well ID#353848 18 rt 30 ft. Sandy;Overburden
5a.Well Location: 30 ft' 50 ft Solid Rock
Hemco Construction ft. -,;-•-r _.
Facility/OwnerName Facility ID# R- f.
(ifapplicable) '' '.L.u'L < VCL.:
595 Troutman Rd, Rockwell ft ft. FL8 I 22021
ftPhysical Address,City,and Zip ft
Rowan 146 098 21.REMARKS ttl,4: Tr.z:,ief;arrsc. e r.i,.•A
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 30 43.533 80 32 59.501
N W 1 12--6. 12LI
6.Is(are)the well(s)ix 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: DYes or '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:
You may use the back of this page!to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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:475 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fdfferent(example-3Q200'and 2@10(7) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resou1 ces,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:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce nter,Raleigh,NC 27699-1636
13a.Yield(gpm)20 Method of test:Weir 24c.For Water Supply&Injection,Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type:chlorine Amount:21A oz 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