GW1-2021-07981_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 TO DESCRIPTION
4449-A 115 fL 195 ft 4GrM
225 IL 265 ft' 2GPM
NC Well Contractor Certification Number 15:'OUTER CASING,fortnulti-cased;wells OR:LINER if a iii icable
Rowan Well Drilling FROM To DIAMETER THICI4VES5 MATERIAL
0 ft. 107 ft' 6 1/4 rn' SDR 21 PVC
Company Name .
355442 A6.�E4NEe CASING OR TusING eothertitsl�lusedaoo
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. fL in.
Water Supply Well: 17._SCREEN—
FROM I TO I DIAMETER I SLOTSIZE F THICKNESS I MATERIAL
Agricultural IDMunicipaUPublic ft. ri- in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft. ;n
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
_I ltrl ation FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 8 bags
Monitoring Recovery ft. ft.
Injection Well:
It. ft.
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVELTACK(if a licit le
Aquifer Storage and Recovery 13Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD µ
Aquifer Test Stormwater Drainage ft ft.
_ Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer a20:%DRILLING LOG attach addifionelsheets ifnecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiVrockY rein s' etc.
0 ft. 15 ft. day
4.Date Well(s)Completed:9/24/21 Well ID#355442 15 ft. 97 It. day/sand/gravel _
5a.Well Location: 97 ft. 107 ft. solid rock
David Brown fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. L i
13475 Statesville Blvd, Cleveland 27013 ft. fL
Physical Address,City,and Zip & ft. If,+
Il.l
PRI�C 'm, .tl
Rowan 264 002 21'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fattlong is sufficient) 22.Certification:
35 44 42.349 N 80 43 23.334 W
6.Is(are)the well(s)I Permanent or OTemporary 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: [3Yes 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 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 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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) 6 Method of test: 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: 15 oZ completion of well construction to 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