GW1-2022-00913_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
140 ft- 150 f6 n cru
4449-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased eells OR LINER if a 'lictible
Rowan Well Drilling FROM TO DIAMETER THICKNESS M1fA7ERIAL
0 ft. 43 ft- 6114 in. I SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-hod
361228
2.Well Construction Permit iY: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell construction permits(i.e.UIC,County State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.FROM SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) ft. ft. in.
:)Industrial/Commercial Residential Water Supply(shared) t&GROUT
(- Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 8 bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
! Aquifer Recharge Groundwater Remediation
19.SAND/G RAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage ft. &
Experimental Technology Subsidence Control ft. ft.
Geothenmal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifssecessa
Geothermal(Heating/Cooling Return) Outer(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/ ck type,gmin size,etc.
0 ft• 19 ft, Clay/sand/shale
4.Date Well(s)Completed: 12/8/21 Well ID#361228 19 ft. 43 ft. Solid Rode
5a.Well Location: <a ft. 53 ft Dirty vein
James&Brittany Rigdon [r. ft. Cs I:'
Facility/Owner Name Facility ID#(if applicable)
1535 Bulldog Ln, Gold Hill 28071 ft. f` JAN 7 2022
Physical Address,City,and Zip ft. ft.
Rowan 539 082 21.REMARKS ==
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22 Certification:
35 32 6.937 N 80 19 23.481 W J 7 2 /
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby cerg&that the n•ell(v)tras(were)constructed in accordance
7.Is this a repair to an existing well: O Yes or @ No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction in formation and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthisfnin. 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 I 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: 185 (fL) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depds if d erent(example-31&200'and 24,D,1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I(water level is above casing,use"I•• 1617 Mail Serviee;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
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) 11 GPM Method of test: °'leer 24c. For Water Stingily&Injection 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: 12 oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Enviromrwntal Quality-Division of Water Resources Revised 2-22-2016