GW1-2021-04637_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 04
Spencer Adams �i y
y y,.. 14.WATER ZONES
;79
MTft- 3405
DESCRIPTION
Well Contractor Name 1 20 ft 1 GPM4449Ar 5 ft• 4 GPM
NC Well Contractor Certification Number n(�i
1��G�1�,3.r t rl.gifJ'jl 15.OUTER CASING for multi cased wells OR LINER if a licable
Rowan Well Drilling FROM TO DIAIYIETER I THICKNESS MATERIAL
Company Name 0 ft 79 ft- 6114 in. SDR21 JPVC
328571 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
_;Agricultural E)Municipal/Public 0 ft. ft in.
:]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
_!Industrial/Commercial IS.GROUT
Residential Water Supply(shared)
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• Holeplug Gravity 9 bags
Monitoring _Recovery ft ft.
Injection Well:
ft ft.
❑Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
(-Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
_=Geothermal(Heating/Cooling Return) _�Other(ex lain under#21 Remarks FROM To DESCRIPTION color,bardnes soiVrock rain sire eta
0 ft- 15 ft- Clay
4.Date Well(s)Completed:4/22/21 Well ID#328571 15 ft 50 ft• Sandy'Overburden
5a.Well Location: 50 f`' 69 "' Broken Rock
Robin Rossi 69 rt• 79 ft- Solid Rock
Facility/Owner Name Facility ID#(if applicable)
ft ft.
1790 Cranwell Dr, Mt Ulla 28125 ft ft.
Physical Address,City,and Zip ft ft
Rowan 558BO42 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 39 57.410 N 80 41 48.814 W L(
6.Is(are)the well(s)e)Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 1 o with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 405 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@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 27699-1617
l].Borehole diameter:6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: 4 `
(i.e.auger,rotary,cable,direct push,etc.) !
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 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: 18 oZ completion of well construction to the county health department of the county
where constructed. 1 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016