GW1-2021-01650_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD fGW-11 For Internal Use Only:
1.Well Contractor Information: ` D
Spencer Adams Y 14.WATER ZONES
WellContractor Name FROM TO DESCRIPTION
4449A pR 2 2U2� 90 ft. 165 a 11 GRM
p n r ft. ft.
NC Well Contractor Certification Number $9�n�
Rowan Well Drilling ati o�p S;,o 15.n FROM TER TO G for muDIA t to v>THICKNESS li�eTEPJ"
Company Nome lxfp ON-re'�y(('��+� 0 ft 45 it' 61/4 hi SDR21 PVC
00000� 16."WER CASING OR TU9ING "thermal dozed-loop)
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2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(ire.WC,County.State,Variance,0 tc.) ft. ft. in• �
3.Well Use(check well use): ft R' tB
WaterSnpply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
Agricultural 0Municipal/Public 0 ft. tt. in.
Geothermal(Heating/Cooling Supply) f�7Residential Water Supp y(single) It, & in.
tndustrial/Commercial E)Resident(al Water Supp y(shared) I&GROUT:
_ hri lion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 26 ft• Holeplu Gravity 8 bags
Monitoring . Recovery ft. ft:
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediati n 19.SANDJGRAVEL PACK f iteabie
Aquifer Storage and Recovery O5aliaity Barrier FROM TO ntATEtuAL EMPLACEMENT METHOD
Aquifer Test oStomtwater Drainage ft. ft.
I
Experimental Technology Subsidence Control (I ft. R
Geothermal(Closed loop) Tracer [ 20:DRi1:Li 4G LOG attach additional sheets ti seeessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) PROM TO DESCRIPTION Le.019r,hardoeM solvmck prM Xmtu size,etc.
0 it. 15 u. Clay
4.Date Well(s)Completed:3/9/21 Well ID#20210 0008 15 ft. 25 rt. Sandy Overburden
Sa.Well Location: 25 r 45 ft. Solid'Rock
David Blythe i 50 ft 95 ft Dirty Veins(water)
Facility/GwnerName Facility M#(ifapplicab ) ft ft'
253 Seminole Trail, New London 271 7
Physical Address,City,and Zip
fL ft.
Davidson 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degreWadautes/seconds or decimal di green:
(ifwelt field,one latttongis sufficient) 22.Certification:
35 30 46.080 N 80 10 28.335 W
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6.Is(are)the weil(s)l�x Permanent or Temporary Sigma f Certified Well C or + Date
By signing this form,I hereby certify that the wvll(s)was(were)constructed in accordance
7.I5 this a repair to an existing well: ElYes or ElNo with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well consruction frrformation and explaln the nata of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. l '
1 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 ito provide additional well site details or well
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of weds construction details. You may also attach additional pages if necessary.
drilled:t ; SUBIMAL INSTRUCTIQNS
9.Total well depth below land surface: 165 ! (ft.) 24a. For All Mills; Submit this'forin within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1M construction to the following:
10.Static water level below tap of casing; (ft) Division of Water Resources,Information Processing Unit,
If rioter level is above casing use + 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.13orebole diameter: (in.) 24b.For Inieetion Welts: In addition to sending the form to the address in 24a
Rotaryabove,also submit one copy of thi form within 30 days of completion of well
12.Well construction method: construction to the following.
(Le.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13s.Yield(gpm) 11 Method of test:weir 24c.for Water 5uggly&folectio Wells: In addition to sending the form to
the addresses) above, also submit�orie copy of this form within 30 days of
Chlorine 14 oZ corn letion of well construction to the coon health department of the
13b.Disinfection type: Amount: P county ep county
where constructed.
Farm GW-I North Carolina Department of nvirunmental Quality-Division of Water Resources Revised 2-22-2016
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