GW1--06933_Well Construction - GW1_20241119

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f Print Form
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: I ` Y
1.Well Contractor Information:
George J Brown Ill .14.WATER.ZONES . i +.
Well Contractor Name
FROM TO DESCRIPTIONI
4654A 200 . ft 220 ft. 7 GPM
300 ft 320 ft 3 GPM I
NC Well Contractor Certification Number 1S OUTER CASING(for Tel wells)OR LINER(If ap cable) - '
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL R
Company Name 0 ' 59 ft. 61/4 '!n' SDR21 IPVC
412120 16.INNER CARING ORT'UBING(geothermal dosed-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(checkwell use): ft ft' In.
Water.Supply Well. 17.SCREEN:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft' ft in.
Geothermal(Heating/Cooling Supply) xoResidential Water Supply(single) yt, ft In. •
Industrial/Commercial OResidential Water Supply(shared) 1S.GROUT - .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20. ft holeplug gravity 6
Monitoring (DRecovery ft. R.
Injection Well:
ft it
Aquifer Recharge Groundwater Remediation 19:SANDlGRAVEL PACK(!f applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
I.
Experimental Technology OSubsidence Control ft. ft.
I.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional Sheets if necessary) .
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(Dolor;hsnloas.duroektype grata sin,etc)
0 it• 45 ft dirt i
4.Date Weil(s)Completed:10/30/24 Well 412120 45 ft. 59 ft solid rock
Sa.WeilLocation: ft.
Madison Praechtl ft, ft, .ti.;: ,,,.�,A._;
Facility/Owner Name Facility MO(if applicable) NO r �J�is
160 Lilly Pad Rd, Granite Quarry ft. �7 F .
Physical Address,City,and Zip ft ft. ir,•;-,„n.... :,--, .F,
Rowan 617C0371038 21.REMARKS • . • . L� .;::: ::}';'. �•
County Parcel IdentificatlonNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22, ertifleation:
35 624775 80 551596
N W " 1(1 '6C i'IA
6.Is(are)the wells)JPermanent or Temporary Si of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or I:No with 15A.NCAC 02C.0100 or ISA 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 ofthis record has been provided to the weU owner.
repair under 021 remarks section or on the back of this fomt.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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'1 SUBMITTAL INSTRUCTIONS I'
9.Total well depth below land surface: 345 (ft.) 24a. For All Wellti: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: i
I
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
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1L 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
rm within 30 days of completion of well
12.Well construction method: ry construction to the following: '
(ie.auger,rotary,cable,direct push;etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test:Weir 24c.For Water Sujmly&Infection Wells: In addition to sending the form to
chlorine 15 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