GW1-2021-08001_Well Construction - GW1_20210809

'Print Form:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1 7
Spencer Adams 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449A 76 ft- 1325 ft• 2 GPM
325 ft 365 ft' 3 GPM
NC Well Contractor Certification Number 15.OUTER CASING formalti-cased wells OR LINER f a licabte
Rowan Well Drilling FROM TO DIAMETER THHCKNESS MATERIAL
0 ft 76 fL 61/4 SDR21 JPVC
Company Name 16.INNER CASING OR TUBING eothermaFclosed-too
2.Well Construction Permit#:353607 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1 e.UIC County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): It. ft. m.
17.SCREEN
Water Supply Well:
FROM TO D1MIETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 fL ft. in.
Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) fa ft. in.
Industrial/Commercial [31kesidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 ft Holeplug Gravity q 6 m,.
Monitoring Recovery ft it.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation 19.SAND/GRAVEL PACK f applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. [t.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatingtCooling Return) nOther(explain under#21 Remarks FROM TO DESCRIPTION color,hudn wil/ruck type,aritin size etc
0 ft- 20 ft- Red Clay
4.Date Well(s)Completed:06/1/21 Well ID#353607 20 n• 50 i ft. Sandy Overburden
5a.Well Location: 50 ft. 66 ft. Weathered Rock
Luis Santana 66 ft- 76 ft- Solid Rock
Facility/Owner Name Facility ID#(if applicable)
R. ft.
1031 Hinsdale Ave, Mt Ulla 28147 ft. ft.
Physical Address,city,and zip
R. ft. (�
Rowan 558AO79 21.REMARKSU11-1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 39 30.860 N 80 42 40.876 W - �
6.Is(are)the well(s)OX Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
1f 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 tinder#11 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-I 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 ifdi3Oerent(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+.' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Rotary above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)5 Method of test:Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlorine the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: rJ OL 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