GW1-2021-07291_Well Construction - GW1_20210809

Print Form-
WELL CONSTRUCTION RECORD(GW-1) 7Forrnal Use Only:
1.Well Contractor Information:
Spencer Adams 14 WATER ZONES
Well Contractor Name FROM TO I DES ON
4449A ft. 2100 "- 3 GPM
ft. R.
NC Well Contractor Certification Number 15.OUTER CASING for malti-cased wells OR LINER d a ticable
Rowan Well Drilling FROM TO DIAMETER T®CHNFSS MATERIAL
tt 6 /4 in sch80 Galvan
Company Name 317857 -
16.INNER CASING OR TUBING ttiertnat cksed•loo
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
Ust all applicable well construction permits(ie.U1C.County,State.Variance,etc.) It. rt. in.
3.Well Use(check well me): /T n In
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 0 ft. IL In
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) g, pr
Industrial/Commercial ®Residential Water Supply(shared) I&GROUT
Lri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n fe holeplug ravity bags
Monitoring Recovery It. IL
Injection Well:
ft. n.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Of applicable)
Aquifer Storage and Recovery E3Sahnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drisinage H. n•
Experimental Technology [3Subsidence Control IL It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets it necessary)
Geothermal eatin Coolin Return) Other lain under#21 Remarks FROM TO DFSCRIPnON color hardness,sonfroek lype,Warn size,eto
ft. It. ay
a.Date Well(s)completed: 6/24/21 Well m#317857 n 7 f Sandy Overburden
Sa.Well Location: Solid Rock
Jeremy Plyler 1 n• 1 0. n. Brown rock/so .1
Facility/Owner Name Facility ED#(ifapplicable) n• ft. 9
3235 Amity Hill Rd, Statesville 28677 ft. ri.
Physical Address,City,and Zip M ft ,
Iredell 4752304073 21.REMARKS
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Ial/long is sufficient) 22.Certification:
35 42 52.053 N 80 50 28.236 W z�
6.Is(are)the well(s)�Permaneat or [3Temporary Signature of Certified Well Contractor Date
Hy signing this form,I hereby certify that the wells)tons(were)constructed in are.ordance
7.Is this a repair to an existing well: E3Yes or u®No with 15A NCAC 02C 11100 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 ivell owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well detar7s:
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
constru on,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional}rages if necessary.
drilled: IT SUBMTAL INSTRUCI•IONS
9.Total well depth below land surface: 305 (R•) 24a, For All Weds: Submit this form within 30 days of completion of well
6or multiple wells list ail depths ifdifferent(example-3(d200'and 2@100') construction to the following:
10.Static watbr level below top of easing: (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 Cm) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method rotary above,also submit one copy of this form within 30 days of completion of well
IL auger,er rotary, construction to the following:
g tary,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&Injection Wells: In addition to sending the form to
chlorine 15 oz the address(es) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016