GW1-2021-01701_Well Construction - GW1_20210323

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Spencer A`aam5 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449A 145 fL 1s5 ft• 4 GPM
165 D• 185 ft• 4 GPM
NC Well Contractor Certification Number 15.OUTER CASING for?!:-coed welh OR LINER Ha Rwble
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATER AL
Company Name 0 ft. 122 fL 6 114 Is- I SDR 21 PVC I Galy
304824 16.INNER CASING OR TUBING other dyed too
2.Well Construction Permit#: FROM TO DIAMETER TMCKNESS MATERIAI.
Lut all applicable xe(t conspuction permits(i.e. U/C,County,Slate, Variance,etc.) fL fL in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT 512E HI TCKNESS MATERIAL
Agricultural )Municipat/Public 0 it. tt. in.
Geothermal(Heating/Cooling Supply) %)Residential Water Supply(single) ft. tL In.
Industrial/Commercial )Residential Water Supply(shared) W.GROUT
hn lion FRO11I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IT- 20 ft- Holeplug Gravity 30 bags
Monitoring DRecovery ' ft ft.
Injection Well: tr. IL
Aquifer Recharge )Groundwater Remediation
19.SAND/GRAVEL PACK H Ilcable
Aquifer Storage and Recovery )Salinity Barrier FROM TO MATERIALI EMPLACEMENT METHOD
Aquifer Test )Stormwater Drainage fL R
Experimental Technology )Subsidence Control ft. R.
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG attach addithmsi sheets if necessary)
Geothermal (Heating/Coaling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION cakr Yard ewvrmk s n dra ete.
0 It- 20 ft- Red Clay
4.Date Well(s)Completed:2/25/21 Well Imo,304824 20 ft- 100 ft• Sandy Overburden
5a.Well Location: too ut 112 H Fractured Granite
Evan Mason 112 H- 122 ft• Solid Rock _
Facility/Owuer Name Facility to#(if applkable) fL ft.
8725 Old Beatty Ford Rd, Rockwell R. ft.
Physical Address,City,and Zip ft. ft.
Rowan 432106 21.REMARKS
County Parcel Identification No.(PIN) t
of galvanized easing at beftem
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latibng is sufficient) 22.Certification:
3531 31.315 N802813.941
W
�- �� z 12 2i
6.Is(are)the well(s))K Permanent or )Temporary Signature of Certified Weil Contractor Date
By signing this form,1 hereby cenify that the well ft)was(were)compacted in aecordonce
7.Is this a repair to an existing well: )Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Comtraction Standards and that a
/fthis is a repair fill out brain wrff rompucdon information and eeplain the nature ofthe copy ofthi.r rerord har been provided to the well owner
repair and,021 remarks sec Han or an the back of this farm. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:T SUBMITTAL.INSTRUCTIONS
9.Total well depth below land surface: 205 (fW 24a. For All Weas: Submit this form within 30 days of completion of well
For multiple wells fut al/depths a ab?erent(e ample-3@200'am12@1001 construction to the following:
10.Static water level below top of casing: 15 (R.) Division of Water Resources,Information Processing Unit,
/(water level i.r abme casing,use"+ ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of this Corm 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test:weir 24c.For Water Suooiv& 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016