GW1-2022-04521_Well Construction - GW1_20220509

' ,Pran_t Form->
WELL CONSTRUCTION RECORD(GW-11 For Intemal Use Only:
1.Well Contractor information:
Spencer Adams f4.- ArEezornes
Well Contractor Name FROM TO 'DESCRIMON
4449-A 205 & US ft .—
345 fL <os ft 10M
NC Well Con1raxor Certification NumberI&01)TERVASIIVG flWinnikkitittl yee0r"OR lampf"Oe
Rowan Well Drilling mom 110 D TMCraysss MATERUL
0 fL 73 fL 6114 SDR 21 PVC
Compapy Nam
22-85W 161DYlYER G"Oa re/anvG rmaleldied-h ?: .
2.Well Construction Permit#: -mom I To I DIAMETER TBICIQIFBS I MATERIAL
IJst all applicable Hell construction permits(t e.WC Comity,State,Ymianae,etc) R fL tn.
3.Well Use(check well use): to
Water Supply Well: ITi.BCREEN ;
FROM TO DIAMEM -:.:.SLOTS= TMCKNESS I MATERML
Agricultural E)MunicipaVPublic ft &
Geothermal ftating/Cooling Supply) Mitesidential Water Supply(single)
fL fL in
Industrial/Cornmercial QResiden ial Water Supply(shared) 18:'GhiOUT
Irrigation FROM TO MATERNAL EMPF.ACEMit METROD A AMOUNT
p
Non-Water Supply Well: o & 20 & "0180 , Gravity 26
Monitoring r3ilecovery ft fL
Injection Welk
Aquifer Recharge QGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FRO AND/GR70 PACK MAIM" I EMPLACEMEN7hIM011
Aquifer Test 13Stormwater Drainage &
Experimental Technology 13Subsidence Control tL tL
Geothermal(Closed Loop) Tracer t0:Dtif1A LNG t0C7 wwiett ddidowd atseee►At" „
Geothermal(HeatinglCooling Return Other lain under#21 Rematks FROM To DFSCMMON caw edtirork dc.
0 iL 15 fL Clay
4/19/22 22-85W ft �.
4.Date Weil(s)Completed: Well[D# 15 63 Sandy/Gay/wea0roradRock
S&Well Location: o ft 73 & Solid Rode.
Karen&Frank Braswell ft ft
Facility/Owner Name Facility IDk(ifappRoMe) fL ft
254 Litaker Lane,Concord 28025 fL ft
Physical Address,City,and zip ft ft
Cabarftls 21,REMAPM
-
County Passel ldentifiwtianNo.(PIN)
ft Latitude and longitude In degr+etshninatea/seconds or decimal degrees:
(if well field,one inUtmrg is sufficient) 2 Certitk7ltion:
35 22 29.464 N 80 34 32.308 W �L�
y
6.b(are)the weil(s)OPermanent or QTemporary Sigoatrne ofCatiSed Well Conmwtor Date
By signing this form,I hereby certify that the well(s)was(were)consmicted in accordance
7,is this a repair to an exhtft*vH: _r3Yes or EINo with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Stmdards and that a
If Ifts is a repair,fill out lmmvn well consuuciton Information and explain the nature ofthe copy ofthis record has been provided m the well owner.
repair tinder 921 remarks section or on Jte back ofthis form
23.Site diagram or additional well details:
S.For GeoprobelDPT 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: 405 (fl-) 24a. For All Wells: Submit this form within 30 days of completion of well
Gor multiple,rells list all depths tfdifferenl(exmnple-3@200'and 2@100) construction to the following.
It Static water level below top of casing: (iL) Division of Water Resources,Information Processing Unit,
Ifwater level is abore casing use"+" 1617 Mild Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (In.) 24b.For Injection 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:
(Le.anger,rotary.cable,direct push.etc:) construction to the following:
l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 276994636
13s.Yield(gpm) 3 Method of test:weir 24a For Wider Sumaly&infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13L Disinfection type: chlorine Amount: isoz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Emirontnental Quality-Division of Water Resources Revised 2-22-2016