GW1-2022-01785_Well Construction - GW1_20220214

rint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 325 ft 345 fL ecaM
4449-A
IL ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6ceble
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 fL 50 ft- 1 61/4 rn• SDR21 PVC
Company Name
2021000081 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft fL in.
3.Well Use(check well use): fL fL im
17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT 617E THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fa ft. in.
J Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Holeplug Gravity 5 bags
Monitoring J Recovery ft. ft.
Injection Well: fL ft
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage fL ft.
Experimental Technology OSubsidence Control fL ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiFr«k type,grain size,etc.
0 ft. 18 ft, Sandy Clay
4.Date Well(s)Completed: 1/13/22 Well ID#2021000081 18 fL 35 fL weathered Rock
Sa.Well Location: 95 ft. 50 ft. solid Rock
Humberto Moreno ft fL
Facility/Owner Name t r tDA1&SV i I C. Facility ID#(if applicable) ft. ft.
1114 Hasty Hill Rd, :Wwt a 27360 ft. ft.
Physical Address,City,and Zip ft. ft. , 4..
Davidson 21.REMARKS
County Parcel Identification No.(PIN) r t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 56 3.763 N 80440.476 W lf�
6.Is(are)the well(s) J Permanent or OTemporary ature 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: [3 YeS or ONO 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: 365 (fL) 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: (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 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) 8 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: 17 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
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