GW1-2021-01690_Well Construction - GW1_20210323

I.Well Contractor Information:
Spencer Adams
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449A k' k• 7 GPM
NC Well Contractor Cemification Number '�, k. k.
Rowan Well DrillingIS.OUTER CASING for mWti-taxed wells OR LINER its lieeble
FROM TO DIAMETER THICKNT MATERIAL
Company Name ft. 4 k' 6 /41n• SDR21 PVC
21-43W 16.INNER CASING OR TUBING hernial closed-Ina
1.Well Construction Permit 1: PROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permus it r UIC,County,State.Variance,e"'
3.Wen Use(check well use): n. n. in.
Water Supply Well: 17.SCREEN
:]Agricultural FROM TO DIAMETER SLOTSIZE TNICKNESs MATERIAL
[]MunicipaVPublic 0 k. n. in.
Geothermal(Heating/Cooling Supply) ©Residential Water Supplyi(singie)
ft. Ft. is
Irrigab aVCommercial Residential Water Supply(shared)
Ill.GROUT
Ilrl xOn FROM TO MATERIAL EMPLACEMEM METHOD 6 AMoumr
Non-Water Supply Wen: k• k• Holeplug ravlty bags
Monitoring Recovery
I tion Well:
n• It.Aquifer Recharge Groundwate Remediatiory Aquifer Storage and Recovery Saline Barrier 19.SAND/GRAVEL PACK Ba
[] ty 1 PROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage k. n.
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) []Tracer 20.DRILLING LOC attach additional diem H
Geothermal leating/Cooling Rehm) rJOther(ex lain under#21 emarks) FROM TO mESC1u l— rotor --.Erie-
k. k• ay
4.Date well(,)Completed: 2/9/2021 well IDa 21-43W', n. k. Solid Rock
So.Wen Location:
Clyde Love
Facility/Owner Name Facility ID#(if appliceble)'I k- D• x� �•
1085 St Johns Church Rd, Concord 28025 n. k.
Physical Address,City,and Zip k. n. O
Cabarrus 56518514610000 z1.REMARK, J
County, Parcel Identification No.(PIN) r EioN 7Crs!,ngS1
Sit.Latitude and longitude in degreesimdnates/seconds or decimal degrees:
(if well field,raw hitting is sufficient) 22.Cerif icaflou:
35 25 55.207 N 80 28 59.818
�-la Zl
6.Is(are)the weII(s)ff1Permanent or QTempormy Srgn a ofCemfied Well Contractor Dale
By signing ties Joan,I hereby cerafp their fie wetl(s)wos(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ©No with 15A NCAC 01C A700 or ISA NCAC 02C.0200 Well Consmacyon Standards and that a
if this is a repair,Jill out known well moseachon infor n ne,and explain the nature'of the copy of this record has been provided a the well owner.
repair order#21 renumks section or on the back of this form.
23.Site diagram or additional well derails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional well site details or well
constmvon,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary,
drilled:
SUBMITTAL INSTRUCTIONS
For 9, nual well depth below land surface: 205 (ft.) 2,ra• For All Wells: Submit this form within 30 days of completion of well
multiple owns less all depths!Jd'fferent(example-3@100'and l@/Oo') construction to the following:
10.Static water level below rap of casing: (R.) Division of Water Resources,Information Processing Unit,
If wrier/nel is above casing,use";"
1617 Men Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary 1.. above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,FOR WATER SUPPLY WELLS ONLY:13a.Yield1636 Man Senice Center,Raleigh,NC 27699.16M
m
(gp ) Method of test: T_ 24c.For Water Supply& Imiectiom We lb, 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
IJb.Disinfection type: Amount: completion of well construction to the county, health department of the county
where constructed.