GW1-2021-03166_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Spencer Adams KWATERZONZS . { k
Well Contractor Name FROM TO DESCRDtttON
4449A 118 rt 125 R- 24 GPM j
R. 0.
NC Well Contractor Certification Number 15 OUTER:CASTNG <armWfi wised wells OR LINER i a lkable
Rowan Well Drilling FROM TO nIAMEiER TlHCKNESS MATERIAL
CompanyName 0 & 1104 tl 61/4 1° SDR21 PVC
226893 :1&INNER CASING OR TUBING eothertml deed-loo
2.Well Construction Permit-#: FRMM TO DIAMETER TMCKNESS MATERIAL
List all applicable well constructionpermits r e-UIC,County,State,Variance,etc.) it ft in.
3.Well Use(check well use): % fL
Water Supply Well: 17 SCREEN,
FROM I TO I DIAMETER SLOTsim I muc-KNw I MATERIAL
Agricultural E3Municipal/Public 0 ft. ft.
in
Geothermal(Heating/Cooliug Supply) Residential Water Supply(single) g ft io
industrial/Commercial OResidential Water Supply(shared) I&GROUT
Irrigation FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 45 R• Hole lug Gravity
Monitoring 1311ccovezy ft ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK a 'ileable
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonn ater Drainage & tt.
Experimental Technology OSubideuc,Control ft ft.
Geothermal(Closed Loop) OTracer 20.:DRE LINGLOG attach additional sbeets1f necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRi InON cobs hardneak sowm& eta
5l13/21 226893 0 � 15 � ft- Red,Clay
4.Date Well(s)Completed: Well ID# 15 90 Sandy Overburden
SR.Well Location: 90 ft 103 IL Solid Rock
Robert Jones/Mike Judd 118 ft 125 It- Fracture 24 GPM
Facility/Owner Name Facility lD#(if applicable) R. ft. .
242 Collingswood Rd, Mooresville 28117 % R.
Physical Address,City,and zip ft. ft r�
Iredell 4638662991 21.P"ARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
35 37 21.596 N 80 53 48.909 W
6.Is(sre)the well(s)0x Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify4hat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or lONo with 15A NCAC 01C.0100 or 15A 1VCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known wen construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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 rimy also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well&pth below land surface: 45 (it) 24s. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Qa 200'and 2Q100) construction t0 the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+' 1617 Mail Servlce'Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in. 1
24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
]2.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)24 Method of test:weir Me.For Water Supply&Infection Well In addition to sending the form to
Chlorine 12 02 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well constnrctior'to the county health department of the county
where constructed. j
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources` Revised 2-22-2016