GW1--01059_Well Construction - GW1_20240212

. Print Form ,`
WELL CONSTRUCTION RECORD(GW 1) For Internal Use'Only: t
1.Well Contractor Information: j 1
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
WellContractorNama 345 ff. 359 + 2 GPM
4449-A 360 n 370 ft. 3 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased hells)OR LINER(If ap llcable)
Rowan Well DrillingFROM TO DIAMETER THICKNESS .MATERIAL
0 ft* 74 1 ft. 61/4 !' P. SDR21 PVC
Company Name
well-11-2023-207827 �OINNER CASING ORTUBIN (geothermalM TO i )
2.Well Construction Permit#: it. g, In.
KNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. j R I 9n.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN I: FROM TO DIAMETER' SLOT SIZE TRIMNESS MATERIAL
[(Agricultural QMunicipal/Public 0 ft ft. in.;
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. in in.
Industrial/Commercial QResidential Water Supply(shared) 18.G1 13T
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD.hAMOUNT
Non-Water Supply Well: 0 f 20; It Holeplug Gravity 8 bags
°Monitoring ()Recovery ft. i ft'
Injection Well: ft. i ft.
Aquifer Recharge QGmundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
[(Aquifer Storage and Recovery [(Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
QAquifer Test QStomtwater Drainage ft. , ft.
()Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) I : 20.DRILLING LOG(attach additional ebeets If necessary)
g (explain under#21 Remarks) FROM TO ` DESCRIPTION(color,hardness,'Wreck tvaa alma eke.etc.)
()Geothermal(Heating/Cooling Return) ['Other 0 f4 15' ft' Clay j ;
4.Date Weil(s)Completed:1/4/24 Well 2023-207827 15 50 Sandy Overburden
Se.Well Location: 50 ft. 64 fL Weathered Rock
Edgewater investments 64 ft. 74 ft. SoiidRock
Facility/Owner Name Facility lD#(if applicable) t ti^ L'LI>3 V•
n
.4443 Giles Ave, Sherrills Ford 28673 ft >ti �'-�afi
ft. ft. t 6 •t2`2024
Physical Address,City,and Zip
460602991298 21.REMARKS ' iv“
�rrq•
CatawbapCounty .1,ar�.;r�
ParcelTdeatificationNo.(PIN) (){tile.1.1 Uali
Sb.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if welt field,ono lat/long is sufficient) 2 Certification:. is2.....____,
1 i Z
35 34 24.978 N 80 59 8.538 w -
Signature of Certified Well Contractor I, Date
6.Is(are)the well(s) Permanent Permanent or }Temporary
By signing this form I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYYes or QX No with 15A NCAC 02C.0100 or I5A 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 oftAlc record Inc been provided to the well owner.
repair under#21 remarks section or on the back of thlsform. 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:405 (&) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple arils list all depths ifdifferent(cc mple-3(g200'and construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mall Sent:etc:ter,Raleigh,NC 27699-1617
11.Borehole diameter:6 (lo) 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.anger,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(BP m)5 Method of test:weir 24c.For Water'Snook,&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this lams within 30 days of
136.Disinfection type:Chlorine Amount 19 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