GW1-2021-04483_Well Construction - GW1_20210429

' - _ ,Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams r',` 14 TER ZONES
%Veil Contractor Name TO DESCRIPTION
4449A Q� c$'` 5 fL 385 rt. 25 cPM'',
P tQ >l, fL tL
NC Well Contractor Certification Number Q $'A Itl_
Rowan Well Drilling. ���o �'
FRO15. LI_— CASING-farmDUMETER .OTHICKNESS a uMA1TERIAL
Company Name �+ �q 0 fL 100 ft 6114 ' 1° SDR21 PVC
336950 J M B2212 16.INNER CASING OR 1 tJBING eotherrnal closed-looni
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,State Variance,etc.)j ft. R. in.
3.Well Use(check well use): Iif ft. ft• in.
Water Supply Well: I 173CREEN
FROM I To I DIAMETER I SLOT SIZE i TnICKN.M MATERIAL
Agricultural 0Municipal/Public 0 fL fL in
Geothermal(Heating/Cooling Supply) ElResidential Water Supply single)
fL fL to
Industrial)Commercial DResidential Water Supply hated) 1$.`GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD h AMOUNT
NOR-Water Supply Well: 0 fL 23 ft. Holeplug Gravity 8
Monitoring ElRecovery
Injection Well:
Aquifer Recharge E3Groundwater Remediation 2 ft.
Aquifer Storage and Recovery `19.SANDIGRAVEL PACK aitcableSaliaity Barrier FROM TO I MATERNAL I EMPLACEMH"METHOD
Aquifer Test E)Stormwater Drainage M R•
Experimental Technology ElSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional sheets if.
FRODf TO -DESCRIPTION color,hard wittrock. Ma
Geothermal eatin Cooiin Return) 'Other(explain under#21 emarks 0 I• 15 I• red Clay
4.Date Well(s)Completed:3/11/2021 Well�336950 15 n so ft- sandv overburden
5a.Well Location: s0 h• 100 I. solid rock
Marshall Bailey ft. ft.
FacifitylOwnerName Facility ID#(ifappficable) ft. ft.
905 W Park Dr, Rockwell 28138 fL
Physical Address,City,and Zip % tt.
Rowan 388 059 21•REMARKS
County Parcel Identification No.(P
5b.Latitude and longitude in degrees/minutes/seconds or decimal d-g—:
(if well field,one lat/long is sufficient) 1 22.Certification:
35 32 30.533 N 80 26 39.746Lit
t ti1' ti--� �11 z t
6.Is(are)the well(s)O% Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.I he-by.certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to as exfsdng well: []Yes or ®NO t with 15A ACAC 01C.0100 or 15A AVAC 02C.0200 Well Constniction Standards and that a
If this is a repair,fill out known well construction information and explain the naturel of the copy of this record has been provided to the well owe,
repair under#11 remarks section or on the back ofthis form. I
1 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saf a 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 welly construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 r (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 1@100) i construction to the following:
I ii'
10.Static water level below top of casing: t (to Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' I 1617 Mail Service Center,Raleigh,NC 276994617
i
11.Borehole diameter:6 (in.) 1 24b.For Infection ells: In addition to sending the form to the address in 24a
Rotar
y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the foAOwing:
(Le.auger,rotary.cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f '
13a.Yield Win)25 Method of test:Airlift 24c.For Water Supply&➢niecdonl'Wells: in addition to sending the form to
Chlorine 18 the address(es) above, also submit one copy of this form within 30 days of
OZ
13b.Disinfection type. Amount: completion of well construction to the county health department of the county
where constructed
I
Form G W-1 North Carolina Department of vimnmental Quality-Division of Water Resources Revised 2-22-2016
i
f