GW1-2022-04483_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD(GW i) Print Form
For Internal Use Only:
1.Well Contractor Information:
Spencer Adams
ZONES-,
Well Contractor Name K-WATER
FROM TO 1.
4449-A 30o ft- 425 ft. l'sCPM1 DESCRIPTION
------------
NC Well Contractor Certification Number 425 ft. 505 ft zsoPu .
Rowan Well Drilling 1&'OUTERCASING for.mWti-cMed;weliy ORIINER ifa lieable
FROM TO DIAMETER TmCKNESS
MATERIAL
Company Name 0 ft. �
52 ff 61/4 1O SDR21 PVC
2.Well Construction Permit#:365536 16rfNNER'CASINlG'OR TUBING' eothernW eldsea-lao"
FROM TO DIAMETER THICKNESS MATERIAL
Lis[all ire!l construction permits(t.e.UIC,Caunry•State,trariance,ete.J ft. fL irr
3.Well Use(check well use): R 8
in
Water Supply Well: !7:SCREEN
Agricultural 0MunicipaVPublic FROM TO DIAMETER n. SLOTSUE THICKNESS MATERIAL
Geothermal(Heating(Cooling Supply) iResidential Water (single) ft ft m
IndustriaVCommercial ft tc in
Residential Water SuPP1Y(shared)
Itri tion M.GROUT
Non-Water Supply Well: FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
.1 Monitoring Recovery 0 ft 21 ft tideplug Gravity 7 bags
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation ft ft.
Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL pACK 'fa cable
FROM TO MATERIAL EMPLACE
Aquifer Test oStormwater Drainage ft ft MENT METHOD
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20;DRILLING-LOG attach additional ibliet,:if neeess.
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION eotor ha eu;urvck
0 f• 19 ft. Clay
4.Date Well(s)Completed:4/4/22 well ID#365536
19 ft 42 ft _ weathered Rode
5a.Well Location: „ ft. 52 2
Solid Rock
Angel Quintero ,t• ft
Facility/Owner Name Facility 1D#(ifapplicable) ft. fL :'e^ n g•^
2480 Gheen Rd,Woodleaf 28147 ft n• '' i'' -
Physical Address,City,and Zip ft. ft _
Rowan 312 110 2L'REMARf(S
County Parcel Identification No.(PIN) ; 4 v i 1 v'r
5b.Latitude and longitude in d g• agrees/minuteslsecondsordecimaldeghees•
(if well field,one lat/long is sufficient) 2 Certif ication:
35 43 49.762 N 80322.204
W
6.Is(are)the well(s)oX Permanent or Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby cerJh that the rvell(s)rear(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or EX No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 R'2l remarks section or on the back eftlris 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-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: 505 (ft-) 24a. For All Wells: Submit this fort within 30 days For multiple wells list all depths ifdierent(example-3@200'and 2@l00) of completion of well
construction to the following:
10.Static water level below top of casing: Division of Water Resou Ifuater level is above casing,use"+ rces,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: in addition 4o sending the form to the address in 24a
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push•etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,INC 27699-1636
13a.Yield{gpm) 4 Method of test: Waif 24c.For Water 6rnr,w �1e,hnn Wel c: In addition to sending the form to
chlorine the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the 1county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources C
Revised 2-22-2016
i