GW1-2021-03117_Well Construction - GW1_20210625

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Paint Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
4449A a
�• 315 E. 10 GPM'
H 485 ft- 17 GPM
NC Well Contractor Certification Number TER CASING for%tl util:wells OR LINER f! Ilgble
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 rt 105 f 61/4 im SDR21 PVC
Company Name .I&IRN ER CASING OR TUBING. eotherinai dosed-loo
2.Well Construction Permit#:we11032021148025 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.WC,County,State,Variance,eta) ft. ft. in.
3.Well Use(check well use): fL ft. In.
W-
ater Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Mtmicipal/Public 0 % tt. in.
I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL to.
Industrial/Commercial E)Residential Water Supply(shared) 18..GROUT,
Irri ation FROM TO r MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 . R• Hole lug Gravity 7
:)Monitoring Recovery f, ft.
Injection Well:
IL ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK11favolleablel.
Aquifer Storage and Recovery E)Sallnity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStomrwater Drainage % ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTraccr 20.DRILLING LOG attach additional sheets If necessa
FROM TO DESCRUMON color,hardness,son/roek tM grain size,eta
Geothermal eatin Cooli Return Mother(explain under#21 Remarks 0 n 20 k Red Clay
4.Date Well(s)Completed:5/11/21 Well ID#148025 20 95 rt. Sandy Overburden
5a.Well Location: 95 ft 105 ft Solid Rock
Chue Xiong fL e
ftcl� Ica
Facility/Owner Name Facility1D#(ifapplicable) Jt ft'
2337 St James Rd, Newton 28658 It. ft
Physical Address,City,and Zip ft ft.
Catawba 21.REMARKS ,
.County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iatllomg is sufficient) 22.Certification:
35 37 16 N 81 1137 W
6.Is(are)the weil(s)ox Permanent or 13Temporary Signature oftertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Ex No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
1f1hb is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional 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 1 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:485 (ft•) 24a. Fir All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2Qa 100) construction to the following:
4
10.Static water level below top of casing:25 0L) Division of Water Resources,Information Processing Unit,
lfw+ater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:5 (In) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of thus form within 30 days of completion of well
1L Well construction method. construction to the following:
(i.e.auger,rotary,cable,direct posh,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)27 Method of test:Weir 24c.For Water Supply&Iniecdon Wells: In addition to sending the form to
Chlorine 17 o2 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.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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