GW1-2021-07937_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-ZONFs
Well Contractor Name FROM TO DESCRIPTION
4449-A 135 ft. 140 fft4Gan
245 ft• 255 ft-
NC Well Contractor Certification Number 15t OUTER CASING formultl-caied,wblls OR=LINER if'a "licable-"
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 fL 93 rt• 61/4 m SDR21 PVC
3 2423 16.'INNER'CASING OR TUBING eothermal closed4o-o ;.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc) fl. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .417.SCREEN
DAgricultural []Municipal/Public
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. tw_)Geothermal(Heating/Cooling Supply) in.Residential Water Supply(single) ft ft. in
Industrial/Commercial Residential Water Supply(shared) 18.'GROUT
Irrt ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 10 bags
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
"1`9.SAND/GRAVEL`PACK`(if a licable`
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
]Geothermal(Closed Loop) Tracer 20aDRiLLING LOG attach additiorial hecfs if recess
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hadness soil/o k type,grain sim,eta
0 ft. 15 ft- red day
4.Date Well(s)Completed:9(2/21 Well ID#312423 15 ft. 80 ft sandy overburden
5a.Well Location: w ft. 83 ft. weathered rock t "� '.r--I I/F,
Foundation Homes 83 ft. 93 ft. solid rod Q�i9
Facility/Owner Name Facility 1D#(if applicable) 100 ft. ,ar ft. dirty vein — cull
140 Morgan Bluff Rd, Mooresville 28117 245 f`- 255 tl
dirty vein DINR SF(nrimi
Physical Address,City,and Zip ft. ft. Ia ..'IATIOAI Mo FRQl1
Iredell 4648065913 21 REMARIC!S .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one IaUlong is sufficient) 22.Certification:35. 37 22.310 N 80 52 56.998 ,l :� 9 1 Z 1 Z 1
6.Is(are)the well(s)oPermanent or Temporary Signature ofCertified 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: []Yes or M 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 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: 265 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below to of casing: 13
P g� (ff•) Division of Water Resources,Information Processing Unit,
If water level is above caring,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: Airlft 24c. For Water Sunoly&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