GW1-2021-01425_Well Construction - GW1_20210910

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-01425
Are you submitting a printed form?* r Yes
C No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Rowan Well Drilling [e-mail]
Is this a revision to the form you have previously submitted?
r Yes F No
WELL CONSTRUCTION INFORMATION
.............................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4449 A SPENCER ADAMS ROWAN WELL DRILLING
2.Well Construction Permit#:
10011679
Listall applicablewell construction permits(i.e.lVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
C Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
9/9/2021 10011679 25
(gallons per minute)"

5.Well Location
Facility/Owner Name
Joshua Davey Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Mecklenburg 01523126
Physical Address* Street Address
8701 Kerns Meadow Lane
Address Line 2
City State/Province/Region
Huntersville NC
Postal/ZZp Code Country
28078 United States
Latitude* 35.2268560000 Longitude't0.5237602000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
345 surface?
Formultiplewells Iistall depths if different 43
(example-3 a200'and 2@100') in feet
11. Borehole diameter:
10.Static water level below top of casing:(ft.) 6
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
25 13a. Method of test:
If applicable Weir
13b. Disinfection type:* 13b.Amount:*
chlorine 12
14.WATER BEARING/FRACTURE ZONES

From To Description
95 100
in feet in feet
325 330 20 GPM
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 43.00 6.25 sdr21 pvc
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 holeplug gravity 23
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 5.00 clay
in feet in feet
5.00 18.00 sandy overburden
in feet in feet
18.00 25.00 black gravel
in feet in feet
25.00 43.00 solid rock
in feet in feet
95.00 100.00 dirty vein/5 GPM
in feet in feet
325.00 330.00 dirty vein/20 GPM
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only

CERTIFICATION INFORMATION
...............................................................................................................................................................
*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
qawmt aw�?W 6
Signature of Certified Well Contractor
Submittal Date 9/10/2021