GW1--04336_Well Construction - GW1_20240722

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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 t DESCRtPT10:4
4449-A 112 ft- 300 ft. 2 GPM
300 ft- 500 fL 1 GPM
NC Well Contractor Certification Number 15.OUTER CASING for mWtl cased n e111 TO LINER f■ llcable
Rowan Well Drilling FROM TO DiAHETER_ TIDCK9ESS MATERiA1.
Company Name 0 it- 1112 6 1/4 in° 1 SDR21 JPVC
2.Well Construction Permit#:
OSWP 2024 49671 1166.OINNER CASING OR TUBIING�eotherma]closed-tom MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. Till
3.Well Use(check well use): ft. ft. T.
Water Supply Well: 17.SCREEN _
FROM i0 DIAMETER SLOT SIZE TMCK.N MATERIAL
Agricultural E)Municipai/Public 0 ft, ft. In.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) —
ft. ft,
Industrial/Commercial OResidential Water Supply(shared) 19.GROUT-Il _
Irfl ation FROM TO MATERIAL_ EMPLACEMENT METHOD&A.mowiT
Non-Water Supply Well: 0 ft. 20 iL Holeplu13 Gravity 6 bags
Monitoring ORecovery ft. ft.
Injection Weil: ft. ft.
Aquifer Recharge [3l rroundwater Ranediation
19.SAND/GRAVEL PACK a licablo_
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [:)Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft. tL
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional aheeh if necesu
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTTO_7 coley,rarda ..Nroct type,grain dze,etc.
0 fa 15 ft- Clay
4.Date Well(s)Completed:6/20/2024 Weil m#49671 15 ft 75 ft Sandy Overburden
Sa.Well Location: 75 102 it. Weathered Rock
Caruso Homes 102 i< 112 it• Solid Ruck
Facility/Owner Name Facility ID#(if applicable) -
504 Fern Hill Rd, Mooresville 28117 ft. ft. . ,.,
Physical Address,City,and Zip ft. IL "
Iredell 4639 98 7515 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweli field,one lat/long is sufficient) 22,C rtilleation:
35 39 17.627 80 53 10.632
6.Is(are)the well(s)EX Permanent or OTemporary Signature o 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: ©Yes or QX No with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knowot we11 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 ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
construction,only I 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: 505 (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'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,]Information Processing Unit,
if water 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 sanding the form to the address in 24a
12.Well construction method:
rotary above,also submit one copy of this firm within 30 days of completion of well(i.e.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
13s.Yield(gpm)3 Method of test:Weir 24c.For Water Supply&Injection 1 s: In addition to sending the form to
chlorine 23 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016