GW1--05080_Well Construction - GW1_20240827

iPrint Form 1
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 102 ft 130 ft• 4 GPM
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased s ellsLOR LINER(if a nimble)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 102 ft- 61/4 10• SDr21 PVC
Company Name , 16.INNER CASING OR TUBING(geothermal closed-loop)
24W
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UJC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. io�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft_ ft, In. —
Industrial/Commercial DResidential Water Supply(shared) Ia.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. HOleplo2 Gravity 29
Monitoring QRecovery ft ft.
Injection Well: --
ft ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK R( appiicableZ
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft.
Experimental Technology ()Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color k • - ealVrock t•.• - . etc.
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft- 20 ft- Clay
4.Date Well(s)Completed:7/15/24 Well m#W 24 8 20 ft 80 tt. Sandy Overburden
5a.Well Location: 80 ft' 97 ft. Weathered Rock
Michael Maness 97 ft 102 ft. Solid Rock
Facility/Owner Name Facility ID#(if applicable) ft. ft.
828 Odell Owen Rd, Lexington ft ft.
r
D. D.Physical Address,City,and Zip
Davidson 1133800000024A 21.REMARKS
County Parcel Identification No.(PIN) ". ',,- -'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if field,one lat/long is sufficient) 22.Certification: '
35
48 49.985 .). -1,(------- I\---Q--------
N 80 17 17.519 W .3 I S L -t
6.Is(are)the wdl(s)I% Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)war(were)constructed in accordance
7.is this a repair to an existing well: QYes or XONo with 15A NCAC 02C.0100 or 15A 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:
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
9.Total well depth below land surface: 245 (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(a 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 Mall 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:
(i.e.auger,rotary,cable,direct push,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test:Weir 24c.For Water SUDDiv&Iniectign Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 12 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