GW1-2021-03165_Well Construction - GW1_20210625

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'=Pnnt'Form:
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: i
1.Well Contractor Information:
__ T
Todd Adams 14;VVATERZONES c 1
Well Contractor Name FROM TO --DESCRIFn !
2522 80 rt- 125 I
380 fL 405 ft' 6 GPM I i
NC Well Contractor Certification Number 1S.OUTER CASING for mWtl-eased�ivells OR LINER f a livable
Rowan Well Drilling FROM DUMErER � 1,fARRIAL
0 ft 60 ft 6.25 '° SDR21 PVC
Company Name O22 16.INNER CASING OR TUBING(geothermal closed,)
2.'Well Construction Permit : FROM TO DIAMETER nUCKNFKR I MATERIAL
List allWhcable well construction permits r.e.UIC,County,Slab Variance,etc.) fL ft. In
3.Well Use(check well use): ft. ft• in.
Water Supply We": 17:SCREEN
FROM TO DIAMETER TSITE THICIOVESS MATERIAL
Agricultural OMunicipaWublic 0 ft. ft, la
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) fL R.
Industrial/Commercial Residential Water Supply(shared) I&GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENTMETaoD&AMOura
Non-Water Supply Well: 0 fL 20 ft- Bentonite Gravity
Monitoring DRecovery ft. ft.
Injection Well:
K it.
Aquifer Recharge [3Groundwater Remediation 19:SAND/GRAVEL PACK f aminewei
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater bminage M tt
Experimental Technology f3subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.`DRILI iNG LOG attach additional sheets if necessary).:
Geothermal(HeatingtCooling Return Other(explain under 421 Remarks FROM TO DESCREMON color,bardu aontrock tM giatm dw,ere.:,
0 ft• 50 ft- Clay
4.Date Well(s)Completed:5/18/Z 1 Well ID#310223 50 rt 40a ft Gra`nite
5a.Well Location: tt. tL
Larry Beresnoy fL ft.
Facility/Owner Name Facility JD#(ifapplicable) ft, ft.
612 Stonemarker Rd, Mooresville 28117 fL ft.
Physical Address,City,and Zip ft. R. �rOLn$S t'
Iredell 4614999801 21.REMAR>SW.
�t>•'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 2:577'
35 31 11.289 N805658.67 W 5 j
6.ls(are)the well(s)Ox Permanent or [Temporary Signature ifCenified well Contractor Date
By signing this form,I hereby certify that the%pills)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or E)No with ISA NCAC 01C.0100 or 15A NCAC 02C.0200 Weft Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of thfs record has been provided,to the well owner.
repair under#21 remarks section or an the back of thisform. 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,oaly 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfaced 405 00 24a.For All Wells:-Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100) construction to the following.
I .
10.Static water level below top of casing: VL) Division of Water water level is above casing,use Resonr
If +" Cte,Information Processing Unit,
2617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 pn) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following j
(i.e.auger,rotary,cable,direct push,etc,)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a Yield Wirt)6 GPM Method of teak Alf 24c.For Water SuDDIv&Inikdon Wells: In addition to sending the form to
Chlorine 28 oz 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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