GW1-2021-00820_Well Construction - GW1_20210215

this form can be used for single or multiple wells
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
PROM TO DasCRD"170N
444 4 Contractor Name 235 ft 265 R 15GPM
9A ft R
NC Well Cormactw Ce,tlfiration Number 11 OUTER CASING for�uki cased wells OR LINER if a bk
Rowan Well Drilling mom TO DAMETER TRICMI MATERML
0 R 45 R 61/4 in. SDR21 PVC
Company Name AP307361 I6 INNER CASING OR TUBING m theral elmeddoe
FRO2.Well Construction Permit#: TO DIAMETER TIIKI(NCS4 MATERIAL
List all a• ft ID.
applicable wrG permits(i.e.C'ounry,Store, Yonmrce,btjenian,etc)
R R a
3.Well Use(cheek well use):
/7.SCREEN
Water Supply Well: FROM To Du SIUTSM TnICtaF.ss MATERIAL
OAgricultural OMunicipw/public It. ft in.
OGeothemod(Heating/COding Supply) BResidential Water Supply(single) R• R In
OlndustriaVCommercial OResidential Water Supply(Shared) IS GROUT
❑kri ation FROM 70 MATERIAL EMM ACEMENF'MEMOD i AMOUNT
Non-Water Supply Well: D R• 20 R HOlepltlg Gravity 14 bags
OMonitoring ORecovery ft R
IajeclioD Well: R R
OAquifer Recharge OGrmmdwater Remodiation 19.SAND/GRAVEL PACK fit astpheablei
OAquifer Storage and Recovery OSallotty,Barrier mom ft To R MATERUL F.aQ1ACFMElr7 atETROD
OAquifer Test OStormwater Drainage
❑Ex rimental Technology R• ft
pe ogY OSubsidence Control
OGeothemtal(Closed Loop) OTrtxer 20•DRILLING I.OG attach ulditimal sheers if actors
FROM TO DESCRIPTION edor,aardvea.wW.k qK veh,the,ek,
OGeotherrnal(Heat in Odin Rearm Clothier lain under#21 Remarks U ft 17 R Red Clay
1/1 5/21 AP307361 17 R 35 R• Sandy Overburden
4.Date Well(a)Completed:Se.Well Location: WeB ID#
35 ft. 45 ft. Solid Rode
Northlake Developers R TL
Facility/Owner Name Facdiry Ina(if applicable) It. ft.
382 Kenway Lp, Mooresville 28117 ft. R•
Physical Address,City,and Zip ft. rL
Iredell 4639310023 21.REMARKS
County parcel Idenfificatiou No.(PIN)
5b.Latitude and Longitude in dtgrees/minutes/seconds or decimal degrees: CerROcaRoD•
(if well field row IatAong,s satfica,at) 22.
35 38 1.624 80 54 29.041 {�
N w � yI Ij I s f z bzr
Srpra[me of Certified Well Contractor Date
6.Is(arc)the well(S): BPermanent or OTempecary
BY signing Ihir form,1 hereby cettify that the well(t)was(were)conrrvcled in acrordancr
with 15A NCAC 02C.0100 or NSA NCAC 02C A200 Melt Construction Standanis and Ihm a
7.Is this a repair to an cabling well: ❑Yes or FIND copy offices record has been provided to the well owner
/f this is a repair,fill our known well emwruchan information and explain the narure r fthe
repair under 421 remarks scram or on the back afthisform. 23.Site diagram or additional well details:
1 You may use the bade of this page to provide additional well site details or well
S-Number of wells constructed: construction details. You may also attach additional pages if necessary.
F'ar mu/tlple injection or nan-water supply wells ONLY with the xame ear,rbucdaA,yaY on,�
soma orreform. 265 e� /L I-BMrfTAL INSTUC7•IONS
9.Total well depth below land surface: - (jL) Us. For All Wells: Submit this form within 30 days of completion of well
For multiple wells ltn all depths i/diJjerent(ewmple-J@200'am12@100') r q nsWetion to the following:
FtB 1 a 20Lf°
10.Static water level below top of casing: (D,) Division of Water Resources,Information Processing Unit,
/1 water level a abase ter: ,6se •--• 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter.— —(iR.) - 24b. For tniection Wells ONLY: In addition to sending the form to the address in
Otalfy 24a above, also submit a 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,me.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Vield(gpm) i15 Method of test: Airlift 24c.For Water Supply @ Injection Wells:
C—h—lofine Also submit one COPY of this form within 30 days of completion of
13b.Dhdufeetloa type: Amount: 12 OZ well construction to the county health department of the comity where
constructed