GW1--06896_Well Construction - GW1_20241118

r
f Print Form
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: 1
George Brown III 14.WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
4654-A 180 ft 200 ft 1/2 GPM
380 ft 400 ft. 1/2 GPM J
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap !feeble)
Rowan well. Drilling FROM TO DIAMETER ' THDCKNESS MATERIAL -
0 ft 112 ft 61/4 in. SDR21 PVC
Company Name 2024 63328
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.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipa1/ ublic 0 ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT
-'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. Holeplllg Gravity 7
Monitoring- - Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) .
Aquifer Storage and Recovery Dsalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft. 1
Experimental Technology OSubsidence Control ft. ft. o
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets if necessary) •
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,eotllroek type shin she,etc.)
' 0 ft 80 ft: dirt 1 1
4.Date Well(s)Completed:10/24/24 Well #2024'63328
m 80 f• 90' ft dirt/rock
Sa.Well Location: 90 it 112 ft-
solid rock
Jeff Roberts ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft..
175 Bostian Lake Rd:, Statesville It H. NOV 1 S 2024
Physical Address,City,and Zip ft. ft.
Iredell 4723 65:5056 21.REMARKS
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/mInutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) I 22. ertifrcation:
35 754171 N 80 9331132 �,6.Is(are)the well(s)Jx Permanent or Temporary Signature of.Certified wet/ -4W
ontractor { ! Date
By signing this form Thereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Elites or EjNo with 15.4 NCAC 02C.0100 or 154 NCAC 02C.0200 Well Constraction Standards and thata
If this is a repair,fill out known well construction information and explain the nature of the copy of Ars record hoc been provideri to tho well ownez
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
consuuctioa,only I GW-1 is neede. 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:425 (ft.) 24a.For All Wells:. Submit this form within.30 days of completit:o well
For multiple wells list all depths if different(example-3Qa 200'and 2@100' construction to the following:
10.Static water level below top of e:tlsing: fft.) Division of Water Reso_,.',_as,Informs os Processing:rnir
If water level is above rasing:aa"+" 16177v,s
ail Service Center,;'sul:.ign,%�`2ia;?-i.=
11.Borehole diameter:O (in.) 'r:ev. r„r Tni,,,5hm Welfl: r .,.i.t:it.,.,',.,,,,,,,i,,g the 4:117r i..me..,,t,!P,., ,-
ri Rot r� above,also submit one copy of thi form within 30 days of completion of well
---- coustmct3oa to die following:
(i e.s•..v:r,o terry,.cable,direct push,etc.) f
. -T l Di Vi.,:mr sii- .iici lcsuari s,iinii:r rusu1ii In icciittu Control Program,
---,=,.�.�.-.�....._ . .... 30- i1ServiceI C 276 9 1636
f-= `,I I �S'v Mail i.;clua`tia,Raleigh,fie ' 9 -
11i =.j� ;.:::::a.:_YY�� _i 2-.4._::in__ Y t.?Encr'Oi .Jiy a,.]IIiullie i iiwis; lu aUtin+UH tu A'CLU mb+Cm:surul IU
i i ii::; adei:.:ti, c,:;) above., alz;; stibrnit ono afy c-f this i,sm;:ithi:: 33C; days of
. .--- _ ._. --_.. [:nir-Willi^ n,,...n.r:• 6 07- 1 c,;:moiction.of well construction to 1the county health department of the county
.- '----- -- = wi+cie cuitsuuciai.
Form GW-i North Caroms nap9.t.;,>:,:ofr..yiPonment:i Qu2E,..y-Division of 'a er F.e:•ou••u< i R,: i cd 2="2016