GW1-2022-06886_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: .+ Ilk.„
Spencer Adams I&WATER ZONES:: : i
Well Contractor Name i FR05I TO DESCRIFFION
44 ft- S00 ft. WPM
4449 A
300 ft- 425 ft2GPM
NC Well Contractor Certification Number 15.OUTERCASING for multi=cised wells FOR LINER'ri livable.
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft- 44 ft- 81/4I' in' SDR21 pvc
2022-00001766 .16AN'NER CASING.OR TUBING"eothermal closed-too
2.Well Construction Permit# FROM I TO I DIAMETER THICKNESS MATERLAL
List all applicable well construction permits(i.e.We.,County,State,Variance.etc.) ft• ft. in.
3.Well Use(check well use): ft ft to
Water Supply Well: '
-FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
:)Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft ft 6 in.
Industrial/Commercial DResidentialWater Supply(shared) 18 GROUT..'
Irri ati6il FROM TO MATERIAL Eh1PLACEbiENrMETHOD&AMOUNT
Non-Water Supply Well: . 0 ft 20 ft* holeplug gravity s
Monitoring DRecovery ft ft.
Injection Well:
ft. it.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL.PACK if a'i livable
Aquifer Storage-and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
_,Aquifer Test OStormwater Drainage ft. fr.
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20,DRiLLING`LOG attec6'additiomalsbeetsif nice.
_Geothermal(Heatin Coolin Return) _ Other(ex lain under 421 Remarks) FROM To DFSCRIPTHOSi color.hardness,soilfrock grain SITE,etc.
0 ft 18 ft• shale t day
4.Date Well(s)Completed:6/24/22 well IDIl 202200001766 18 e. 44 ft.
solid rock
Sa:Well Location: W fr. 84 ft brawn rock
Gene Basham 130 ft- 170 ft brorarock �-qrq,�• .3 Oa
Facility/Owner Name cihty ID#(ifapplieable)
ft. ff.
Fa
1915 Thayer Rd, Trinity 27370 rt. rr. JUL 112022
Physical Address,City,and Zip ` ft. ft
Randolph 7714012441 21..REn1ARres - m� nli.t
County Parcel Identification No.(PIN) n i1'viii�Il'I PROCESS-JS-ING 1JN1I
I,.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iat/iong:is sufficient) 22.Certification:
35 47 2.025 N 79 58 38.012 W
6.Is(are)the well(s)OPermanent or [3Temporary Signature ofCcrtiSed Well Conha, ; . Date
By signing this form.I hereby ce�tJ&that the weff(s)u•as(irere)contructed in accordance
7.Is this a repair to an existing well: QYes or JNo with 15A NCAC 02C.0100 or ISA ItiCAC 02C.0200 Nell Consintelion Standards and that a
If this is a repair,fill oul known well construction information and erplain the nature of the copy of this record has been provided to the irell owner.
repair under 921 remarks section or on the backof this 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 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: 425 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(emtnple-3@200'and 2 rut 100) construction to the following;
10.Static ivater level below top of casing:35 (ft.) Division of Water,Resources,Information Processing Unit,
Ifivater/ere/is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 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
]2.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) 4 Method of test:Weir 24c.For Water Supply&Injection Wells: In addition to sending the farm to
chlorine
the address(es) above, also submit one copy of this form within 30 days of
ce zooZ
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