GW1-2021-07963_Well Construction - GW1_20210809

Pant'-orm -,
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
SPENCER ADAMS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
157 ft- 1.5 GPM
4449A ft 41 rL
3.5 GPM
NC Well Contractor Certification Number 1&OUTER CASING or multi canal wells OR L[NER to (cable
ROWAN WELL DRILLING FROM TO DIA 1R! TTIICIQI1E38 MATERIAL
( ft 6 1/4; In SDR21 PVC
Company Name 79483
16.INNER CASING OR TUBING eothemtal closed-1
2.Well Construction Pert U• FROM 1 Ito 1 DIAMETER TMCKNESS MATERIAL
Ust all applicable eve/l construction permits(i e.UIC.County,State.Variance,etc.) ft. ft. ID.
3.Well Use(check well use): ft. ft• in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural E3Municipal/Public ft ft. Ira.
Geothermal(Heating/Coohng Supply) EIResidential Water Supply(single) ft to
Industrial/Commercial r3ftesidential Water Supply(shared)
I&GROUT
rrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0 ft. 20 'ft- HOLEPL
Monitoring DRecovery H. "It,
Injection Well:
ft. n
Aquifer Recharge [313roundwater Remexliation 19.SAND/GRAVEL PACK applicable)
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage it. (L
Experimental Technology ®Subsidence Control ft. EL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attaeb additbaal siseets it oecesW
Geothermal eatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color hardness,solvfnek type,Wain diT,etc.
ft. 2
4.Date Weil(s)Completed: 6/10/21 Wen m#79483 ft. M SANDY OVERBURDEN
So.Well Location: 147ft. ft' SOLID ROCK
FRANK MALONE It. rL
Facility/Owner Name Facility IDH(if applicable) ft ft. 6*
11905 SHiNN RD, MT ULLA 28128 ft nve
Physical Address,City,and Zip ft. rt. M"' Ilan
ROWAN 760065 21•REMARKS t
County Parcel Identification No.(PiN) 6-0119
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
35 42 3 N 80 41 24.034 W t u 'ter
6.Is(are)the well(s) Permanent or Temporary Signa use of Certified Well Contractor Date
By signing this form,I hereby certh that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or �It No svith 15A NCAC 02C D100 or 15A NCAC 02C.0100 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 farm.
23.Site diagram or additional well details:
S.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
constru on,only 1 OW-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: 425 (fL) 24a•For All Wens: Submit this form within 30 days of completion of well
For multiple wells Hsi all depths if lii fereni(example-3@200'and 2@1001 construction to the following:
10.Static tinter level below top of casing: OL) Division of Water Resourves,information Processing Unit,
If water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iuiecdon Wells: In addition to sending the form to the address in 24a
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.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 5 Method of test: AIRLIFT 24c.For Water Suoph&Injecdon Wells: In addition to sending the form to
CHLORINE 18 OZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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