GW1--06224_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information: I : ,
Spencer Adams 14.WATERZONES 1
Welt ContractorName FROM TO DESCRIPTION,
4449-A 124 ft• 400 ft• 2 GPM
400 ft 500 ft. 4 GPM I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If op linable)
Rowan Well Drilling FROM TO DIAMETER' THICKNESS MATERIAL
0 ft 124 ft• 61/4 'la' SDR21 PVC
C2.Well OSWP 2024 55817 16.INNERASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft ft. ln.
3.Well Use(check well use): ft ft. In
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 f t. ft la
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, it In.
Industrial/CommercialResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERW. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Hoiepiug Gravity
Monitoring DRecovery ft ft.
Injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(t[applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL E NPLACEl11ENT METHOD
Aquifer Test OStormwater Drainage it. ft.
13xperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,somroetrtype,wain eke,etc.)
0 ft 20 ft, clay 1 I
4.Date Well(s)Completed:8/19/24 Well m#202455817 20 ft. 100 ft• Sandy Overburden
5a.Well Location: 100 ft• 119 ft. weathered rock
First In Flight 119 ft 124 ft• solid rock
Facility/Owner Name Facility lD#(if applicable) ft, ft. =-'. ,.. 'C.'.` ':._..
167 Ruby Rd, Mooresville 28117 • ft ft. q n ,e I... ,:' .1..,l.J
Physical Address,City,and Zip ft ft. nil- ? 7(174
Iredell 4635 39 6143 21.REMARKS 1
County Parcel Identification No.(PIN) Ir.-., ...i`.`=1 P'T..rC,..,M,^7itt t+,fi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22. rtification• ,,,,,A5 4.____.
35 32 47.528 N 80 54 14.715 ��-W / 124-
6.Is(are)the well(s)Cx Permanent or Temporary Signature of Certified Well Connacto; i Date
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By signing this form,I hereby certl that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or [)No with 1SANCAC 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 ofthe copy of this record has been provided to the lwell 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't SUBMITTAL INSTRUCTIONS ;
9.Total well depth below land surface:505 (ft) 24a.For All Weiss: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3Qa 200'and 2Q1001 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
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11.Borehole diameter.6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable;direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm)6 Method of test:weir 24c.For Water Snooty&Injection Weis: 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: 23 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