GW1-2021-00804_Well Construction - GW1_20210215

This form can be used for single ar multiple wells
1.Well Contractor Information:
Spencer Adams 11/FROMWATER ZONES N
Well Contractor Name 145 R. 205 a 6 GPM
4449A fL rt.
NC Well Contractor CMifi®tioo Number UL OUTER CASING For maltlramd wens OR LINER If• bk
ROM TO DL ETER THr(.T(NEHS MAte
Rowan Well Drilling 0 a 98 w s 1fa a. SDR21 P
Company Name Ilk INNER CASING OR TUBING eathermal eloxd-lao
we1I122020142831 PROM TO DLOIETER THICKNESS MATERIAL
2.Well Construction Permit N: ft.
R. io.
Litt all applicable well permits f.e.Cowry.Slate•Partonee,injection.etc) @. I ft it
3.Well Use(check well east): 17.SCREEN
FROM I TO I DIAMETER I SIM SIZE I 'eHIG1CN[Sa MATEarAI.
Water Supply Well: A IL ie
OAgicultmal OMunicipaUPublic
R o
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft.
Olinim rial/Commercial Oftesidential Water Supply(shared) 1&GROUT
ROMI TO MATERIAL D1HMAC0MT METHOD&AMOUNT
Olrtt ation 0 R. 20 a Holeplug Gravity 34 bags
Non-Water Supply Well: R fL
OManitoring ORecovery
fL
Injection Well: R.
OAquifer Recharge OGroundwater RemnAiation 19.SANDIGRAYEL PACK dapplicable)
FROM I To MATERIAL tuff ACEMENTMLTOOD
OAquifer Storage and Recovery OSalinity Barrier R, fL
OAquifer Test OStormwater Drainage h R.
❑Experimental Technology OSubsidence Control =D,pgILLING LOG attach additional sheets if oeeessa
OGeotherrnal(Closed loop) OTmcer tmose I TO DEs .'.N .uu'waa.1%wiaroca nla ebe«e
OGeothermal (Heating/Cooling Return) OOlher etc lain under N21 Remarks 0 P. 15 R Sandy Clay
1/20/21 wel[122020142E 15 ti 80 D, Sandy Overburden
4.Date Wells)Completed: Well IDN 80 R. 88 fL Weathered Rock
5s.Well location: 88 R. 98 R. Solid Rock
Mario Vassallo fL a
Facdity/Owner Name faulu,ID'Ot apPhcoble) h. &
8390 Slate St, Terrell 28682 fL rL
Ph icaI Addrtss,City,and Zip 2L REMARKS
87 tawba 461703328476
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well fwld,one IaUlong is sufficient) `/`►�'+.—Ca[J�
35 34 53.958 80 58 16.294 W I �-►o (tl
Sigrteme acertinvit Wen Coaaactm Date
6.Is(art)eke wed(s): laPefmanent or OTemporary q�^e P)�signing this farm,I hereby renh AC the )was(were)ci;mirouni aped in,and that.
with ISA NCAC OIC.0/00 or lSA NCAC 02C.0200 We/7 Consbnctian&andorQs and thm n
7.is this a repair to an cabling well: OYes or ENO "` copy of this record has been Proeded to the well owner.
Ijdris is a repair,fill oat known well crmuruction hjonnation and esploin theT 1692123.
(drfl OZ,�Sin diagram or additional well details:
repair miler ell remarks section or on eke back oft/ruform. i't L
1 You Ty me the back of this page to provide additional well site details or well
p
S.Number of wean constructed: '•n�"- B.r."''t�nsfrugion details. You may also attach additional pages if necessary.
`'i1 i" r
For multiple injection or non-wmer supply wells Owy wah the kohretygY�y 10)1 SUBMITTAL INSTUGTIONS
submit one farm. 205
9,Total well depth below land surface: (D.) 24a. For All Wells: Submit this form within 30 days of completion of well
Formuhtplewells listalldepthe if different lerampla-3@200'and2@100') construction to the following:
w Division of Water Resources,Information Processing Unit,
or Static water level below lop of ruing: (R') Division
Mail Service Center,Raleigh,NC 27699-1617
Ijater ln�el is above cnsing.6use"'"
24b.For Infection Wells ONLY: In addition to sending the forth to the address in
Il.Borehole diameter; (In.)
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction mcthod: ft�lA� construction to the following:
(i.e.augOr,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigh,NC 27699-1636
6 Airlift 24c,For Water Supply&infection Wells:
13s.Yield Method of test;(iPm) Also submit one copy of this form within 30 days of completion o
Chlorine 12 OZ well concoction to the county health department of the county where
13b.Disinfection type: Amount' constructed.