GW1--06199_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
George Brown HI 14.WATER ZONES :' I l • •'
Well Contractor Name FROM TO DESCRIPTION
4654-A 245 ft. 265 R. 3 GPM ; i
NC Well Contractor Certification Number 385 405 ft. 6 GPM j
1S..OUTER CASING(for multi-cased wells)OR LINER(If ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 82 61/4 SDR21 PVC
416329 .16.INNER CASING OR TUBING(geothermal closed.loop) .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft R.. !n
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER. SLOT SIZE- THICKNESS MATERIAL
! QMunicipal/Public 0 R, ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM 'TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 tt HOleplug GRavity 9
Monitoring ORecovery ft. R.
Infection Well:
•
Aquifer Rechargeft R.
q [Groundwater Remediation
Aquifer Storage and Recovery Salim Barrier 19.SAND/GRAVEL PACK(if applleabie), ' • .• . •
ty FROM ,TO MATERIAL ; EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft, a
Geothermal.(Closed Loop) ' Tracer
20:DRILLING LOG(attach additional'sheets if necessary).
Geothermal(Heating/Cooling Return) IlOther(explain under#2I Remarks) FROM TO DISCRIPTTON(Dolor,nardaecs eoi0roektype orals da chat
9/23124 416329 6o dirt 1 brown rock
4.Date Well(s)Completed: - Well ID# 60 R. 70 R. brown rock
5a.Well Location: 70 ft 82 ft' solid rock
Pamela &William Allr d ft ft. - : -
Facility/Owner Name FacriityMil(if applicable) ft. ft. -'r, <' _,..py, ; .'w1.....,';%,W
17112 Mooresville d, Mt Ulla fw ft rT 1) 1 7(i74
Physical Address,City,and Zip ft. ft. U i..l -'
Rowan 576 061 21.REMARKS : - r`,r•:e, ;.d s s.
County Parcel Identification No.(PIN) ' i 1%: 'o a` `-ram
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is 22.C cation:
36 617854 N 0 741546 W j
6.Is(are)the wells) x Permanent or I�TTem o Signature of Certified Well CC ntractor Date
u py
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 ON° with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this La a repair,fill out known well cons ion information and explain the nature of the copy of this record has been provided to the xell owner.
repair under#21 remarks section or on the ck 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-Lo p Geothermal Wells having the same
construction,only 1 GW 1 is needed. dicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1
SUBMITTAL INSTRUCTIONS •
9.Total well depth below land aorta •:405 (R.) 24a.For All Wells: Submit this fowl within 30 days of completion of well
For multiple wells list all depths Ifdif erent example-3@200'and 2@100' construction to the following:
10.Static water level below top of :;tag: (n, 1
Ifwater level is above casing,use"+" ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (In.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Ro ary above,also submit one copy of this urn 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 0 I Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)9 Method of test:weir 24c.For Water Sapaty&Infection Wells: In addition to sending the form to
chlorine the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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