GW1-2021-01721_Well Construction - GW1_20210323

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WELL CONSTRUCTION RECORD (GW-1) For Irate nal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
mom TO DESCRIPTION
Well Contractor Name 97 it- 385 IL 2.5 GPM
4449A
ft. I R.
NC Well Contractor Certification Number 15.OUTER CASING for mdd-emed webs OR LINER B ble
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 h• 97 It 61/4 1n SDR21 JPVC
CompanyNeme 313060
16.IN CASING OR TUBING wthermal clamed-too
2.Weil Construction Permit#: FROMI TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permin(.e.UIC County,Smts, Variance,etc) b- h. In.
3.Well Use(check well use): IL I It. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SWTSIM THICKNESS MATERIAL
Agricultural OMonicipaVPublic p h R. In.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) rt. h in.
Industrial/Commmial OResidential Water Supply(shared) I&GROUT
_Jbirigation FROM' TO MATERAL I "WIACLWENTMETHOD&AMOUNT
Non-Water Supply Well: 0 h 20, h• Holeplug Gravity 22 bags
Monitoring 131tecovery h ft
Injection Well:
h ft
Aquifer Recharge QGmundwater Remediation
19.SAND/GRAVEL PACK Ruble
Aquifer Storage and Recovery Salinity Barrier FROM I TO IMAIERW. EMPWCEMENTMETmm
Aquifer Test OStonnwater Drainage ft, ft.
Experimental Technology OSubsldeace Control ft. h
Geothermal(Closed Loop) OTmcer 20.DRILLING LOG attach additional been If sm ma
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks mom TO DESCRIPTION nor\arch rlYreek . ele.
0 fL 18 h• Red Clay
4.Date Weil(s)Completed:2/23/21 Well In„313060 18 ft. 87 I Sandy Overburden
5a.Well Location: 87 h 97 fL Solid Rock
Ricky Tedder fL f"
Facility/Owner Name Facility lD#(if applicable) h f. --
204 Lakeview Shores Loop, Mooresville 28117 h• h
Physical Address,City,and Zip
Iredell 4627208644 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/wands or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
80 56 27.799
35 34 37.553 N W
Z �27I21
6.Is(sre)the we8(s)Ox Permanent or OTemporary Signature of Certified Well Contractor Dam
By signing this form,l hereby cernfy that the wellol was(were)constructed in accordance
7.Is this a repair to an existing web: []Yes or OK No with l5A NCAC 02C.0100 or 15A NCAC 02C 0200 Well Construction Standards ad that a
Ifthis is a repair.fill ll out known we0constraction information and explain the nature afthe copy of this record has been provided to the cce/l owner.
repair under#27 remarks section or on the back of this form.
23.Site diagram or sddltloail 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You my also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent feesample-3(g200'am12@7001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If wafer Level is above racing.use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b. For Inieetfon Wells: In addition to sending the form to the address in 24a
Rotary above, 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,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2.5 Method of test:Airlift 24c.For Water Supply& Injection Wells: In addition to sending the forth to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 17 OZ completion of well construction to the county health department of the county
where constructed.
Form G W-1 Noah Carolina Department of Eavironmcntal Quality-Division of Water Resources Revised 2-22-2016