GW1-2022-01794_Well Construction - GW1_20220214

c Prirt.Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 44rWATERZONES ,.=
Well Contractor Name FROM TO I DESCRIPTION
4449-A 100 fL 115 fL
230 fL 260 fL
NC Well Contractor Certification Number ,115:OUTER CASING fon:mul6 cased.wells`OR LINER if a' 'cable
Rowan Well Drilling FROM TO DIAMETER THIC74VESS MATERIAL
0 fL 80 fL 61/4 'n' SDR21 PVC
Company Name cc
10012485 =`16:�INNER';CASING OR'TUBING Both ed er'malelds -lob":-,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft' 1n.
Water Supply Well: i47'SCREEN,._a �.,;a
FROM TO DIAMETER SLOTSI7a THICKNESS MATERIAL
Agricultural E3MunicipaVPublic fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in.
Industrial/Commercial OResidential Water Supply(shared)
•,it&GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fL 20 fl. Holepig Gravity
Monitoring Recovery fL fL
Injection Well:
h fL
Aquifer Recharge Groundwater Remediation
--A 9.SAND/GRAVEI:PACK if S'P 'cable `
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage fL fL
_ Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer =",20:.DRILLING LOG Omaich additioriel sheets if aeccs = r
Geothermal(Heating/Cooling RetReturn) Other(e FROM TO DESCRIPTION color haidnes soilhoek etc)lain under#21 Remarks) 0 fL 12 fL Red Clay
4.Date Well(s)Completed: 1/7/22 Well ID#10012485 12 fL 62 & Sandy overburden
Sa.Well Location: ft. 70 ft Weathered Rode
Thomas Karbowski 70 ft. 80 fL Solid Rod
Facility/Owner Name Facility 1D#(if applicable) ft. ft. `
4945 Harrisons Sabbath Dr, Huntersville 28078 ft. ft t
Physical Address,City,and Zip fL ft.
Mecklenburg 013 221 32
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 24 25.818 N 80 57 15.316 W I �1 �-z-z
1�
6.Is(are)the well(s)oPermanent or Temporary Signature ofCerufied 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: 13Yes or [9No 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 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: 265 (It) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3 r@200'am12@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) 17 Method of test: weir 24c.For Water SuDDIv&Iniection 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, 16 oz 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