GW1--02899_Well Construction - GW1_20240510

I '
z-,f,lilitiiikiiiiitN71
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !'
1.Well.Contractor Information:
Spencer Adams 14:WATER ZONES,:.:- : ::.I.:::r::: - :; .::
Well Contractor Name FROM TO DESCRIPTION
4449-A 45 rt 425 ft' 1/2 GPM I !
ft ft.
NC Well Contractor Certification Number 18::OUTER CASING(for multi•cuied wellf).ORLLNER Of up linable),::;
Rowan Well Drilling FROM TO DIAMETER , THICKNESS MATERIAL
company Name 0 ft' 45 ft. 61/4 !n'' SDR21 PVC
08 2023 202584 '1166OnvNER.CASINGORTUBIM TO A a aleloie ::,:THICKNESS MATERIAL '
•
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC Corarry,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): ft, ft In.
Water Supply Well:
FROM TO DIAMETER SLOT Sam THICKNESS MATERIAL
Agricultural °Municipal/Public 0 ft. ft in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in. ,
Industrial/Commercial °Residential Water Supply(shared)
--.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 . ft 20 ft- Holeplug GRavity 10 bags
Monitoring °Recovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater ltemedlation 19.SAND/GRAVEL-PACK Of aeolhable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft ft.
Geothermal(Closed Loop) °Tracer :2O;DRILLING LOG(attach additional sheets Uneca iry)' .:':::.. .:.:
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM To DF$CRIPIION(Dolor,Madam,mop/ma type,grain du,etc.)
0 ft• 15 ft. Sandy Clay
4.Date Well(s)Completed:4/2/24 Well ID#082023202584 15 ft, 30 ft. weathered rock
Sa.Well Location: 30 ft. 45 ft' solid rook
Cline Custom Builders 45 ft, 425 it soft burgundy rock
Facility/Owner Name Facility ID#(if applicable) ft ft.
1501 Misty Lane, Hickory 28601 ft ft* 1-;9 r- =-, " ,,Z-,.,.
Physical Address,City,and Zip ft R. "•<`dv_L +d 1.,, ,,d
Catawba 373515649401 21 REMARKss:; .:_;:_ ;:..MA;'" :`.t:204
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one latllong is sufficient) 22.Certification:- .I�t.-s
35 48 6.342 N 81 14 6.622 w p / 4 11_ f-a 4
6.Is(are)the.wells) x Permanent or Temporary Signature of Certified Well Contractor j Date
By signing this form,I hereby certify that the wells)was(were)cansbucied in accordance
7.Is this a repair to an existing well: °Yes or X)No with 15A NCAC 02C.0100 or15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair ill out known wellconstrnation information and explain the nature of the copy of this record has been provided to the,s well owner.
'weir 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 TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled'i SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface:425 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,#ereni(example-3®200'and 2©100) construction to the following: i
10 Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If seater level it 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
•
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test:weir 24e.For Water Supply&Infection 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 OW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016