GW1-2021-02573_Well Construction - GW1_20210811

Prinf: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
4449A ft n 3 GPM
R. �.
NC Well Contractor Certification Number is;ou1ER.CAMG Owmutti-cased wells PRUNER t a" liable
Rowan Well Drilling FROM TO DIAMETER TmcKNEss MATERIAL
R H, 61/4 10 18.5 Galvan
Company Name AP310754
16.INNER'CA6INGO$TUBING Itermatclased-too
2.Well Construction Permit N: FROM TO D ETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC.County,State,Variance,etc J- ft. f It. in. V�.
3.Well Use(check well use): ft- ft in.
Water Supply Well: t7;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMusricipal/Public 0 H. ft. in.
:]Geothermal(Heating/Cooling-Supply) EiResidential Water Supply(single) n rL in.
Industrial/Commercial Residential Water Supply(shared) 1&GROUT i
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It, 4 It. Holeplug Gravity 10 ags
Monitoring Recovery ft. ISS* H- FL" 320 ( .2s
Injection Well: It. ft
Aquifer Recharge Groundwater Remediation
19,SAND/GRAVEL RACK" applicable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage It. ft'
Experimental Technology E)Subsidence 4ntml ft• ft
Geothermal(Closed Loop) Tracer 2&DRILLING LOG attach additional sheets if necessary)
Geothermal Heatin Coolin Return. Other(ex lain under#21 Remarks) FROM TO DESCRIMON eolar hardm�sdVrockt oHu ern
ft 4 R aye
4.Date Wen(s)Completed: 7/21121 Well ID#AP310754 ft- 115 IL Sandy,Overburden
So.Well Location: 115 ft- 120L Weathered Rock
Stephen Zwillling 1 (ft• 13( n Solid ock
Facility/Owner Name- Facility tDff(ifapplicable) ft. ft.
335 Honeycutt Rd, Troutman ft. ft. i
Physical Address,City,and Zip H. ft y
Iredell 4730513663 21.REMARKS V
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/mioutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22. rtration:
35 39 47.044 N 80 5414.901 W �"'
�D- I
6.Is(are)the well(s)oPetmanent or 13Temporary Si ure Certified Well Camractot Date
s' ling this form,1 hereby certify that the well(s)was(were)constructed in-acrordance
7.Is this a repair to an eiristing well: [3Yes or E)No r 15A NCAC 02C A100 or 1 SA 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 buck of this form.
23.Site diagram or additional well detar7s:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional well site details or well
construe on,only i GW-I 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: 405 (B) 24a.For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example.3a@200'and 2 aG1100') construction to the following
10.Static*ater level below top of casing: (ft.) Division of Water Resources,Info.nation Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 Cm) 24b.For Iniection 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 Mari Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 3 Method of test: Weir 24c.For Water Supply&r Injection Wells In addition to sending the form to
Chlorine 18 oz the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: 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
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