GW1-2021-04649_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: E
1.Well Contractor Information: g
Spencer Adams 0.', 14.WATER ZONES
Well Contractor Name (t om FROItt TO DESCRIPTION
4449A ,� 2021 240 M 285 fi-I't 9GPM'
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NC Well Contractor Certification Number V n
415.0Rowan Well Drilling
�,���, t v�t?CC.� OYi FROM LITER CTOSING-(for.muDl ed wells ORHICKNEsLINER if a IiMATERMLL
Company Name % r- 0 ft 103 ft 6 1/4 '° SDR 21 JPVC
327 t] 16.INNER CASING OR TUBING eotherma[closed400
2.Well Construction Permit#: f C7 FROM TO DLUIETER I THICKNESS MATERIAL
List all applicable xrll construction permits(I e.UIC,County,State,Variance,etc.) tt. ft. in.
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft ft. in.
Geothermal(Heating(Cooling Supply) )Residential Water Supply(single) R. ft. in.
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
lrri ation FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Holeplug Gravity 21
Monitoring ' .Recovery ft. ft.
Injection Well: =
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK f applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control k• tt•
Geothermal(Closed Loop) DTracer 20.DRILLING LOG lattach additional sheets if necessary)
Geothermal(HeatingtCooling Return) nOther(explain under 421 Remarks) FROM I TO DESCRIPTION color,haraa wiurock type,grain size etc.
0 ft. 15 ft. Red Clay
4.Date Well(s)Completed:4/15/21 well ID#327183 15 ft so ft• Sand ,Overburden
5a.Well Location: 80 ft• 93 ft. Weathered Granite
Roseman Construction 93 ft- 103 ft. Solid Rock
Facility/Owner Name Facility ID#(if applicable) ft ft.
3060 Potneck Rd, Woodleaf 27054 ft. ft.
Physical Address,City,and Zip ft. fL
Rowan 814 025 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iat/long is sufficient) 22.Certification:
35 46 8.049 N 80 33 39.155 W � Yy 2
6.Is(are)the well(s)e)Permanent or OTemporary Signa[u fCeriified Well Contractor Date
By signing this form,1 hereby certify that the ivell(s)ww(were)constructed in accordance
7.is this a repair to an existing well: OYes or QNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair ender#21 remarks section or on the back of this form.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3t200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 276994617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of iris form within 30 days of completion of well
12.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 ServiceiCenter,Raleigh,NC 27699-1636
13a.Yield(gpm)9 Method of test:Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:Chlorine Amount: 15 OZ completion of well construction to`the county health department of the county
where constructed. i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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