GW1-2021-00819_Well Construction - GW1_20210215

his form can be used for single or multiple wells
L Well Contractor information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 200 ft. 245 a 6GPM
4449A D. FL
NC Well Contractor Certification Number 1S OUTER CASING far naW-cued weib OR LINER f■ ble
Rowan Well Drilling FROM TO DL TLR TRIMNI MS MATERIAL
0 h. 84 tt 61/4 in. SDR 21 PVC
Company Name 509686 16.INNER CA THICKNESS OR TUBING dwrnui dated-I.n
MATERIAL 2.Well Construction Permit#: FROM TO� ft DIAMETER
List all applicable well permits(,.e.Cowry,.909e,Pariann,Injection,etc.)
R 3.Well Use(eM1cek well use): R. in.
17.SCREEN
Water Supply Wtft: FROM TO DIAMETER SIATSE E THICKNESS MATERIAL
OAgricultural DMunicipaMblic IL ft in.
DCmothermai(Heating/Cooling Supply) EIResidential Water Supply(single) D• ft. In.
❑Endustria/Commenial OResidential Water Supply(shared) I&GROUT
Obtl0hon FROM TO NUTpaAL Ehrl A rME Ron&A VIIT
Non-Water Supply Well: it. 20 fL Holeplug Gravity 15 bags
OMonitorinS ORecovery FL tt
InjeeElon Well: R n.
OAquifer Recharge OGroundwater Remediation 19.SANDICRAYEL PACK ifs cable
DAquifer Storage and Recovery OSatinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwuter Drainage ft. N
OExperinentai Technology OSubsidence Control ft. R-
OGeothermal(Closed Loop) OTracer 20.DRILLING Ll7G attach additional sheep if necessa
FROM TO DESCRIPTION nobs Arid w wk Ins etc.
OGcothermal(HeatingtiCisoling Return OGther ex lain under#21 Remarks) 0 fL fL Red Clay
1/13/202- 509686 20 fL 60 a sandy overburden
4.Date Well(s)Completed: Well ID#
60 H. 74 FL Weathered Rock
Se.Well Location:
Bryler Builders 74 R• 84 e. Solid Rock
Fadity/Owmr Nome Facility ID#(if applicable) a fL
126 Hanes Bee Lane, Mooreville IL a•
physical Address,City,and Zip h. R.
Iredell 4624 29 8727 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreestmlautes/seconds or decimal degrees:
Gwen field,are 682 is ssdncient) 22.Certification:
35 31 11.682 80 56 23.404
N
w
6.Is(an)the well(a): mPermaceut or OTemporary Sigoatnn,ofCemfied Wen Contractor flee
By rtg"me ehlr form,!herehy cerrIfy that the"I/A)war(were)cowirswed in accordance
with I5A NCAC 02C'.0/00 or 15A NCAC 02C.0200 Well Comametiw Stmdards and that a 7.Is this a repair to an existing well: DYes or EBNo copy of this record has been provided to the well owner.
l/this a a repair,fill oat brown well carnunchon information an d arpfgbt(hf soame ofdre
repair wukr e21"Marks.smrion or on the back ofthu,/orm. 23.Site ellagram air 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: qtt construction details. You may also attach additional pages if necessary.
her multiple injeamm or nun-wmersapply wells ONLYwithther yuA',j
submit one form. 245 SUBMITTAL INSTUCTIONS
9.Total well depth below Isad surface: ! (ftj 241s. For All Wells: Submit this form within 30 days of coat letion of well
F'or multlp/e we/Ls/ist al/depths i/d�erem(-,;,p/e-3000'and 2Q�Op);. construction to the following: p
10.Static water level below top of using: (rt,) Division of Water Resources,Information Protesting Unit,
Ifw er level ishrg above cw ,we"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. Ear Infection Welk ONLY: In addition to sending the forth to the address in
rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Weft construction method: construction to the following:
(i.e,auger,rotary,cable,direct pwh.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(ePm)
6 Method of test: Airlift 24c.For Water Supply&Intention Wells:
Chlorine 1 rJ oZ Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount: well construction to due countyun
health department of the coty where
constructed.