GW1-2021-01702_Well Construction - GW1_20210323

This form can be used for single or multiple wells
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
EROM ro DescRlrrron
Well Contractor Name _ 68 ft. IT& f, 1 1 GPM
4449A 300 ft 425 ft. 1 GPM
NC Well Contractor Certification Number �1�`� (( � 2�21 IS.OUTER CASING for etald-eafN wdN OR LINER ifa "tahk
Rowan Well DrillingPROM lb DIAMETER THICKNESS MAlER1AL
"�` 0 ft. 68 ft. 6 1/4 in. I SDR21 I PVC
Company Name C•- - I6.INNER CASING OR TUBING thermal closed400
198388 mom TO DIAMETER TIHCKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I ID.
List all applicable well permits(i.e.(ounty.State, Variance,Inje,tion.etc)
ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: PROM TO DIAMETER SLOT SIZE TIIICKIiE55 MATERIAL
ft. ft a
❑Agricultural ❑MunicipaLiPublic
OGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shaped) IS GROUT
FROM I TO lilikn . I EMPLACEMENTMETHOD&AMOUNT
Olt-figation 0 EL 20 ft. Holeplug Gravity 9 bags
Non-Water Supply Well:
IL ft.
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge OGroundwater Remediation 19.SANDIGRAVEL PACK Ba Ids
PROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery ❑Salinity Barrier R. fL
OAquifer Test ❑Storrnwater Drainage
ft. fL
[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG apaeh addideul sheets if aecrosa
❑Geothermal(Closed Loop) OTracer mom TO DESCRD'TTON eotur,Wd.e iod/roca in surt etc
OGeothermal (Heating/Conlin Return 00ther(explain under#21 Remarks 0 ft. 20 M Clay/Sand
2/1/2021 198388 20 fL 58 fL Sand/3/4-1"Gravel
4.Date Well(s)Completed: Well ID# 58 ft. 68 ft. Solid Rock
Sa.Well Location: fL ft.
Mike Lee
fL fL
Facility/Owner Name Facility IDH(if applicable) -ft. ft.
0 Johnson Dairy Rd, Rockwell 28138
R. h
Ph iral Address,City,and Zip 21.REMARKS
f wan 370 052
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seaonds or decimal degrees: 22• ertification:
(if well field,one looters is sufficient)
35 32 15.312 80 22 43.660 ✓ 2l l Z u r 1 N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or OTemporary By vgning this form. I hereby certify that the well(s)was(were)constructed in accordance
with 15A N('A('02C.0100 or 15A NCAC 02( 0200 Well('onstrucnon.Standard,and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner
lfthis is a repair,fill out known well construction information and esplaln the nature of the
repair under=21 remarks section or an the back at this firm. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
for multiple injection or non-water supply well.,ONLY with the saute c'aremnarc inn.you can
,ubma one form. 425 SUBMITTAL ENSTUMONS
9.Total well depth below land surface: (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
I or multiple wells list all depths itdiifereor(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
if water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
li 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
2 Airlift 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
Chlorine Amount: well construction to the county health department of the county where
constructed.