GW1-2021-02606_Well Construction - GW1_20210811

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES r
Well Contractor Name FROM TO I DESCRIPTION
4449A ft. 17 GPM
n. fL
NC Well Contractor Certification Number IS.OUTER CASING or motti-eased wells OR LINER to licebte
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 n n• 61/41In. I SDR21 PVC
Company Name A N 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
list aft applicable it-ell construction permits(i.e.UIC,County,Stare,Variance,etc.) Hr
n. in.
3.Well Use(check well use): • n, in.
Water Supply Well: M SCREEN
FROM . TO DIAMETER SLOTSrLE THICKNESS MATERIAL
Agricultural OMunicipal/Publia 0 ft. n. In.
Geothermal(Heating/Cooling Supply) 131tesidentiall Water Supply(single) n. n• In
tndustrial/Commercial Residential Water Supply(shared) 1&GROUT
X Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n 20 IL Holeplug Gravity 16 bags
Monitoring Recovery
Injection Well: „
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage n. ft.
Experimental Technology [3Subsidence Control ft. n•
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional'sheets If necessary)
Geothermal(Heating/CoolingReturn Other ex lain under#21 Remarks F0 R- To DFstl Gl eotor sWuroelc e«
tt. a ay
4.Date Welt(s)Completed: 7/1/21 Well lD# NA n. 86 n- Sandy Overbuy
Sa.Well Location: 86 n Solid Roc ,
Jason Connelly/APC2 n n.
Facility/Owner Name Facility IM(ifapplicable) iti n• <\
335 School St, Cleveland 27013
Physical Address,City,and Zip f4
Rowan OL"F(/a 01"1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/mimrtes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22•Certification:
35 43 35.032 N 80 40 54.598 W
6.Is(ore)the weil(s)O%Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or x)No with 15A NCAC 02C A100 or 15A NCAC'02C D200 Well Construction Standards and that a
If this is a repair.fill out Renown well construction information and explain the nature of the copy of this record has been provided to the rcell owner.
repair under#21 remarks section or on the back of this farm.
- 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
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: 325 (fL) 24a. For All Wells: Submit this tort within 30 days of completion of well
For multiple wells list all depths if differem(exampt-7@200'and 2@100) construction to the following:
10.Static water level below top of casing: to (fL) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (w•) 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 Supply&Iniection Wells: In addition to sending the form to
Chlorine 17 oZ the address(es) above, also submit lone copy of this form within 30 days of
13b.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