GW1-2022-06746_Well Construction - GW1_20220603

Print Form,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
112 fL 225 & mosv !
4449-A
225 ft 325 ft. +saw
NC Well Contractor CertificationNumber 1S'OITiER'GASING fermidtFcased*e%4RVNEIt 11
Rowan Well Drilling FROM TO DIAMETER TMCIaVESS MATERIAL
0 tt 112 R• 6114 I% Sdf21 PVC
Comparry Name 16.EWCM CASING OR TUBING eothermiddosed-lua _
2.Well Construction Permit!I. FROM FROM TO I DIAMETER I 11HIC NESS MATERIAL
List all applicable well conrtrucrfan permits(Le.U1C,County.St rC tarlawe.etc.) /L I L I I.
3.Well Use(check well use): 1} I tt is
Water Supply Well: 17.SCREEN
FROM TO . DIAMETER I SLOTSIZE I THICKNM MATERIAL
Agricultural OMunicipal/Public % ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft ,
Industrial/Commercial Residential Water Supply(shared) I8 GROiP1
bri on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R 20 R H RWW t'm* 13
. Monitoring Recovery IFL fL
InjectioD Well:
ft &
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM ND/GRAVEL`PAC1C ble
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage n. ft.
Experimental Technology QSubsidence Control fL fL
Geothatnal(Closed Loop) 13T-ea 20 DPAIAANG iOG •ttiehiQdttioniiialreeiiit
Geothermal Heatin Olin Return Other(explain under 421 Remarks FROM TO DESCItd•770N eobr wiytoe)< ern
0 & 15 & day
4.Date Well(s)Completed:5/18/22 WeB i1#322798 15 & so & sandy overburden
52.Wen Location: p0 IL 102 & weathered tack
Coryingram 102 11 112 R sobdrock
Facility/Owner Name Facility ON(if applicable) ft &
174 Country Brook Lane,Mooresville ft. ft P Izar-- .-
Physical Address,City,and Zip
fd
Iredell 467417 2428 Z1 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes(seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
35 30 58.231 N 80 46 37.067 W
6.b(are)the wen(s)MPermaneut or QTemporary SignaturefCertifiuxs Well Contractor Date
By signing this form,1 hereby cerilfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or InNo with 15A NCAC 02C.0I00 or 1SA NCAC 02C.0200 Well Construcilon Standards and that a
lfthis is a repair,fill out known well construction Information and explain the nature ofthe copy of this record has been provided,to the well owner.
repair under 421 remarks section or on the back of iris form
23.Site diagram or additional well details:
&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: 325 -(it.) 249. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depihr 9 Verent(example-3@200'and 2®1M construction to the following:
i
10.Static water level below top of castag:35 (M) Division of Water Resources,Information Processing Unit,
tfi ater level is above casing,toe"+" 1617 Mao Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24L For Infection Wells: In addition to sanding the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
IL Wen construction method: construction to the following:
(i.e.auger.rotary.cable,direct push.eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)25 Method of test:weir 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fort within 30 days of
13b.Disinfa4ion type: chlorine Amount: 15 oZ completion of well constructi to the country health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviromacmal Quality-Division of Water Ls Revised 2-22-2016