GW1-2021-07927_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams .14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
75 ft. 8o n' 4GPM
4449-A
205 It, 240 ft sGrM
NC Well Contractor Certification Number '15.OUTER CASING formulfi-case8 wells UR I INER if a likable x -
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft• 53 ft- 1 61/4 1 SDR 21 1 PVC
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20LOOOn7 ;16tINNER'CASING'ORTUBING `eotherrnslclosed-loo _ ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate, Variance,etc.) ft. ft. rn•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 47-SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]MunicipaVPublic fL ft in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft ft. in
IndustriaUCommercial Residential Water Supply(shared) „18 GROUT. .< ".,
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Grvaity,21 bags
Monitoring [)Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
"l9.SAND/GRAVEL`PACK if a 'licatile `' A,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test [3Stormwater Drainage ft• ft.
:)Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 13Trdcer `;20.,DRILLING LOG ittach additional sheets ifnecess
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillmck type,grain size,etc
0 ft. 10 ft. day/sand
4.Date Well(s)Completed: 0/26/21 shell tD#2020009 10 ft 30 fL sandy overburden
Sa.Well Location: ft. 53 ft. solid rock
Harold Penick 87 ft- 96 ft- brown/pink rock dirty
Facility/Owner Name Facility ID#(if applicable) 112 ft- 116 ft' brown/pink rock dirty
$975 Huff Farm Rd, Kemersville 27284 fa ft.
Physical Address,City,and Zip ft. ft. r�
Forsyth 21.'REMARKS`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 01i41Z 3LrG'
36 11 23.493 N 80231.619 µ 9r� u4i I�l rftOCES$l�G 1
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6.Is(are)the well(s)oPermanent or Temporary Signature ofCertfied well Contractor Date
0y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JqNo 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 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Ciosed-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: 265 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdifferent(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 30 (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 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: Weir 24c.For Water Sunnly&Infection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016