GW1-2021-07930_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 TODESCRIPTION
4449-A 180 ft- 260 ft. —
325 ft• 365 ft• acne
NC Well Contractor Certification Number 15:`-OUTER CASING for multi-cased wells OR LINER La ficli e
Rowan Well Drilling FROM TO DLIMETER THICKNESS MATERIAL
0 ft. 91 ft. 61/4 ut. SDR21 PVC
Company Name
342 163INNER GASiNG'ORTUBING eothermal'closed-loo ,
2.Well Construction Permit#: 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. in.
Water Supply Well: FROM
SCREEN".,..'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipaUPublic It. ft. in.
_ Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft. ft. in
:,)industrial/commercial Residential Water Supply(shared)
]8;GROUT'
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Holeplug Gravity 13 bags
Monitoring [)Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.iSAND/GRAYIsL PACK ifa ticable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
i Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .20:DRILLING;LOG.attach.additionalsheets'ifnecessa
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillmli type,groin size,etc.
p ft. 20 ft. day
4.Date Well(s)Completed:9/17/21 Well ID#13421 20 ft. 81 ft
sandy overburden
Sa.Well Location: 81 ft 91 ft solid rock
Roger Garcia ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft v t, � x 4F
1710 Rhyne Rd, Dallas 28034 ft. ft. NOV 2 2
^
Physical Address,City,and Zip fL ft
Gaston 21.=REMARKS ;Z. r,: �,r
4�, ,1 r1t av ter.
County Parcel Identification No.(PIN)
rllr��11 c
v re 'iVl I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 22 25.409 N 81 815.050 W,
6.Is(are)the well(s)@)Permanent or Temporary Signature off•Certi/5ed•Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or E)No 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 ofthis 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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi-{ferem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 00 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) 7 Method oftest Weir 24c.For Water Supply&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: 19 oZ completion of well construction jto the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016