GW1--06931_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George Brown Ill 14.WATER ZONES . .. . I • •
WeIlConbactorName FROM TO DESCRIPTION
4654A 60 ft. 80 ft. 10 GPM
245 ft. 265 ft- 5 GPMi
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedwells)OR LINER(If ap l cable)
Rowan Well Drilling FROM TO DiAMETER THICK MATERIAL
0 n' 67 ft. 6 1/4' I°. SDR21 PVC
Company Name 412139 16.INNER CASING OR TUBING(geothermalclosed loop) '
2.Well Construction Permit#: FROM ►o DIAMETER R THICKNESS ss MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc) ft ft. ' In.
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 g, ft. m,'
OGeothermal(Heating/Cooling Supply) x[)Residential Water Supply(single) ft. ft. In.
DlndustriallCommercial DResidential Water Supply(shared)
Ilhriaation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f- 20 ft. Holeplug •Gravity 15
QMonitoring if Recovery ft. ft.
Injection Well:
Aquifer Recharge OGroundwater Remediation
•19;SAND/GRAVEL PACK(If applicable)
DAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology
ft.
ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING I OG(ettaeh'addluonal sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,e ludo en,.owroet<type,atria its,,ere.)
0 ft. 40 Dirt i
4.Date Well(s)Completed:10/9/24 We ID#412139 40 ft. 55 ft. Dirt/Reck
5a.Well Location: 55 ft' 67 ft' Solid Rock
Evan Newton ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. G .'—.i ,'ii..-., ;/ Q.-,2.,_6'
1085 Cedar Hill Rd, Rockwell ft. ft.
Physical Address,City,and Zip
ft. NOV 1 £LJtT
Rowan 374D039 21.REMARKS _' _ .. .:,....,;.:�:., ,;.,:,,
County Parcel Identification No.(PIN) I DF': =..::i
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(if welt field,ono tat/long is sufficient) C rtlllcation: q /
35 528513 N 80 452998 W i t , 1 /
Signature of Certified Well Co
6.Is(are)the well(s)0Permanent or TemporaryDate
By signing this form,I hereby cert0 that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or ONo with ISA NCAC 02C.0100 or!SA NCAC 02C.0200 Well Construction Standards and theta
If this is a repair,fill out lamwn 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
Willed:t ,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:285 (f) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifs:Werent(example-3Qa 200'and 2Qa 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 Infection Wells: In addition to sending the form to the address in 24a
rotaryabove,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,eta.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)15 Method of test:weir 24c.For Water SRDDiv&Injection Wells: In addition to sending the form to
chlorine 12 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 OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
.