GW1-2021-04639_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,,� a.^•. . j
Spencer Adams e _
14.WATER ZONES
Well Contractor Name t,y� 4 r� �O 58 FROM fL 300 R• , GPM
RmTtON
4449A l 1 t
r�Fnrt?rci;+��`}il 00 rL 325 rt. 12 GPM
NC Well Contractor Certification Number
Rowan Well Drilling `t J t I f� Y GII FROM To
CASING for multi cased wells OR LINER if a licable
`tiV`�" FROM TO DIAMETER THICKNESS MATERIAL
0 rt 58 ft. 6 1/4 . '° SDR 21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
352886
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft. @, in.
3.Well Use(check well use): fL ft. rn•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL.
:]Agricultural E]Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) MI Residential Water Supply(single) ft. g, in
" Industrial/Commercial QResidential Water Supply(shared) 18.GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 20 rt Holeplug Gravity 11 bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
- Aquifer Storage and Recovery ]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks FROM TO DESCRIPTION color,nardn somrock type,graiinsize,etc.
0 rL 12 rr• SandyjClay
4.Date Well(s)Completed:4�28�21 Well ID#352886 12 rL 48 rr• Weathered/Broken Rock
5a.Well Location: 48 n• 58 ft' Solid Flock
Frances Howe
Facility/Owner Name Facility 1D#(if applicable) ft ft.
2840 Lentz Rd, China Grove 28023
Physical Address,City,and Zip fL ft.
Rowan 127109 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 32 39.014 N 80 32 59.143 W )4�� q (2g ZI
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MIND with 15A NCAC 02C.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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (It-) 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 2@1001 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
11.Borehole diameter:6 (in.) 24b.For Injection 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: EEEV
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)3 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
Chlorine 15 oz completion of well construction to the coup health department of the
13b.Disinfection type: Amount: P � county eP county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016