GW1-2021-07929_Well Construction - GW1_20211122

Print Forrri'�'"
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14-WATER-ZONES
Well Contractor Name FROM TO DESCRIPTION
285 ft 405 ft 4GPM
4449-A
ft. ft
NC Well Contractor Certification Number 45%OUTER CASING(far roulti cased wells OR LINER ifa lic"able
Rowan Well Drilling FROM TO DLIMETER THICKNESS MATERIAL
0 ft 96 ft' 6 1/4 to SDR 21 PVC
Company Name
13520 16:INNER CASING OR zuBINe �euthermal c►osed=loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft fL in.
3.Well Use(check well use): ft. ft- in.
.17.:SCREEN
Water Supply Well:
.
FROM TO DIAMETER� SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft. ft in.
:]Geothermal Geothermal(Heating/Cooling Supply) Residential Water Supply(single) IL fr. in.
Industrial/Commercial 1KGROUT
Residential Water Supply(shared)
! 1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 40 ft. Holeplug Gravity 8 bags
_;Monitoring ORecovery ft. ft.
Injection Well: It. ft.
3. Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK(if a'licable rIl
Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_!Aquifer Test OStormwater Drainage ft. ft
Experimental Technology 13 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 40:,DRILLING.LOG attach additional shee&itoecessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiVmak type,grain size,eto
0 ft. 20 ft, red day
4.Date Wells Completed:9/20/21 Well ID#13520 40 fL 86 ft sandy overburden
5a.Well Location: „ & 96 ft. solid rod r ti—f
William Renneberg ft. fr. n f
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9033 Wagon Trail, Lincolnton 28092 ft rL rt=fro bl~UIIUN,
Physical Address,City,and Zip fL fL "'°" v1 I1 8JING VIM I
Gaston 2LREMA
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 23 45.967 N 81 15 22.034 W v f 4_ __� 617 I� I
6.Is(are)the well(s)f9Permanent or Temporary 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: O Yes or E]No with 15A NCAC 02C.0100 or 15A NCAC 01C.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 421 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-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 UL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: (fl.) 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
139.Yield(gpm) 4 Method of test Weir 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: t9 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