GW1-2021-07932_Well Construction - GW1_20211122

71,
Print Form_
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 44.WATER tZONES -
Well Contractor Name FROM TO DESCRIPTION
4449-A 245 ft 285 ft zcw.
345 ft' 375 ft
NC Well Contractor Certification Number 15:,OUTERCASING.for•inulti-cased wells OR'LINER ira`'likable ,
Rowan Well Drilling FRoM To DIAMETER THICKNESS MATERIAL
0 ft 101 fL 6 114 1 SDR 21 PVC
Company Name
,13605 a6INNER"CASING"OR TUBING 'eo"thermal 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. fL in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.:SGREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_;Agricultural DMunicipal/Public ft. ft is
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft ft ;,t
IndustriaUCommercial Residential Water Supply(shared) 48,GROUT'
Irrigation FROM TO ,MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Holeplug Gravity 15 bags
Monitoring Recovery ft ft
Injection Well: ft. ft
D. Aquifer Recharge Groundwater Remediation
l9.SAND/GRAVER"PACK if ii likable" ' ;.
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD m
:)Aquifer Test [DStormwater Drainage ft ft
:)Experimental Technology OSubsidence Control ft. ft
_;Geothermal(Closed Loop) Tracer 20:_DRILLING-LOG attach additional sheets`if necessa r"
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardnws,soitl o k tyM grain s' etc.
0 ft. 25 fL Gay
4.Date Well(s)Completed:9/14/21 Well ID#13605 25 ft. 91 ft sandy overburden
5a.Well Location: s, ft 101 ft• solid rock
Ronda Baine ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3307 Boat Club Rd, Belmont 28012 ft ft
Physical Address,City,and Zip ft ft
Gaston 21 REMARKS';°r t:f
County Parcel Identification No.(PIN) •P•
t' .`�,1�G 1I -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 12 10.775 N 81 123.106 W Ste_ 17,1
6.Is(are)the well(s)JRPermanent or Temporary Signature of Certified Well Contractor Date
By signing this Jorm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or X)No with 15A NCAC 02C.0100 or/SA 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 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferenl(example-3 a200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/fwaler 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) 4 Method of test: Weir 24c.For Water SuDDIv&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: 16 oz completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016