GW1-2021-04673_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: g
Spencer Adams ,� R'�7 14.WATER ZONES,
Well Contractor Name j— FROM i TO DESCRIPTION
4449A t Ay 2021 240 it 285 ft 9 GPM'
IL rt.
NC Well Contractor Certification Number v r[ 15.
Rowan Well Drilling r?CM1' O�Y`, FRO�ERCTDSING formul�ETERells 01THI(5NEESSta IrMATERIAL
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Company Name v ` 0 it 1103 ft- 16 1/4 in SDR 21 JPVC
327 A 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I 18 FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
17.
Water Supply Well: FROM SCREE TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL _
Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(Heating(Cooling Supply) )Residential Water Supply(single) B. ft. in.
Industrial/Commercial )Residential Water Supply(shared) Ig,GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Holeplug Gravity 21
Monitoring ` _Recovery ft. %' ft.
Injection Well: ft. it.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK f applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
.Aquifer Test OStormwater Drainage ft. ft.
i. Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardn willrmit rain sin,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM
ft. 15 ft• Red;Clay
4.Date Well(s)Completed:4/15/21 Well ID#327183 15 ft 80 ft Sandy Overburden
5a.Well Location: 80 ft' 93 rt' Weathered Granite
Roseman Construction 93 ft. 103 it. Solid Rock
Facility/Owcer Name Facility ID#(if applicable) ft. ft.
3060 Potneck Rd, Woodleaf 27054 It. rt.
Physical Address,City,and Zip ft. ft.
Rowan 814 025 21•REMARKS
County Parcel Identification No.(PIN)
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51.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 46 8.049 N 80 33 39.155 W
6.Is(are)the well(s)OPermanent or QTemporary Signatu of Certified Well Contractor Dale
By signing this form,I hereby cerlijy'thal the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair,f ll out known well construction information and explain the nature of the copy of this record has been provided io the well owner.
repair ender#21 remarla 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:t 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 ifdifferent(example-3 al 00'and 1Q100) 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�Ccnter,Raleigh,NC 27699-1617
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 this 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 Service Center,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
Chlorine 15 oz completion of well construction`to the coup health department of the coup
13b.Disinfection type: Amount: P h P h
where constructed.
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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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