GW1-2022-06898_Well Construction - GW1_20220718

i
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: 4
Spencer Adams la::wAlzotiss }
Well ContractorName > FROM TO I DESCRIPTION l
4449-A 109 % 220 % s cw I
1260 � 309 rL 1 a GPM
NC Well Contractor Certification Number -IS.G TER EASING forivu]t1=ca+ed vens OR LINER fd eaMe "^
Rowan Well.Drilling inn°M To I DIAMMR MUCK'Fss MATERIAL
0 ti 1 109 ft- 1 6114 1- s6R21 PVC
CompairyName I61)TiNERGASINGORTIIBING eutherniat:dosedloo
Z.Well Constriction Permit#: 13600 FROM TO DIAMETER TMCKNESS
h1ATERW
List aUappticabie we11 consinictian permits(r.e.WC,County,Stare,Parlance,etc)
3.Well Use(check well use)-
Water Supply Well: r c
PP y FROM TO D1Ae>Ei'ERR SLOTSt7E IT61CIQa:SS MATERIAL
Agricultural E]Municipai/Public L m in.
Geothermal(Heating/Cooling Supply) fflfkesidential Water Supply(single) % fL
IndushiaUCommercial �Residentiel Water Supply(shared) l8 GROITP<'''il'
Irrigation FROM TOMATERIALEMPLACEWENrMETHOD&AMOUNT
Non-Water Supply Well: 0 f6 20 Hateplug Grm*16bags
Monitoring Recovery ft. % b
Injection Well: IL ft. -
yuifer Recharge Remediation
_ ;19:SAND/GRAVEG-PAGIC 6fAnn)lei tAe ,
Aquifer Storage and Recovery DSalinity Barrier -FROM TO MATERIAL EntPl.acEMENr METROD
Aquifer Test [3Stormwater Drainage
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer :IO DRILLING'LOG'ottiehadditiun�l stieenlf
Geothermal eatin Conlin Return Other lain under#2I Remarks F1tOM To DESCRIPTION(color,burin smuroek sae s
0 f4 12 fw Clay ISand
6fl3/22 13600 rt. n.
4.Date Well(s)Completed: WeU ID# 1z 90 sans overburden
Sa.Well Location: eo tr' 99 fL Weatlwed Road
Cornerstone Properties Ill 99 D 1o9 ft- sorid Rork
Facility/Owner Name Facility M/i(ifapplicable) ft., R.
231 St Marks Ch Rd,Cherryville 28016 ft. I R P C F-m-1 C
Physical Address,City,and Zip
Gaston 1622086 zfTssMARlcs= _ _
4
County Parcel Identification]v*o.(PIN)
5b.Latitude.aad longitude in degrees/minutes/seconds or decimal degrees: ��,T
(if well fiel(,one Wong is sufficient) 21 ert�cAtion: �Z� '- Vi IL7)PR GE50 iG l �
35 21 6.140 N 81 20 55.835 W 3 I zy
6.Is(Are)the well(s)MPermanent or Temporary Sigmtiae of Certified Well C or Date
By signing rhts form,l hereby certify that Ore urtl(s)was(were)constructed In accordance
7.is this a repair to an existing well: ElYe9 or XMNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200{Yell Construction Standards and that a
Ifrbisir a repair,fill out lmown well construction information and-plain the nature ofthe copy ofthis record has been provided to the well mvnet.
repair under#21 remarks section or on the back ofthisfomr
23.Site diagram or additional well details:�
8.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-I is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface; 305 fft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depihs lfdifferent(example-3,ag200'and 2@1001 construction to the following:
i�
10 Static water level below top of easing: (ft•) Division of Water Resources,Information Processing Unit,
If iraw level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
if
11.Borehole diamete 6 fn.) 24b.For Injection Wells: In addition to sen
ding the form to the address in 24a
above also submit one copy of this form within 30 days of completion of well
12.Well construction.method: Rotary construction to the following:
(i.e,auger.rotary,cable,directpush.eta)
Division of WaterRegourees,Undergrouad Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-1636
139.Yield(gpm)i0 Method of test:Air Ldl 24c.For Water Suoniv&Injection Wells: In addition to sending the form to
the address(es) above also submit one copy of this form within 30 days of
Chlorine completion of well construction to the coup health department of the
13b.Disinfection type: Amount: P ,ty departot county
where constructed
r
Form GW-I North CorolinaDepartment of Etwironmewal Quality-Division of Water Resources Revised 2-22-2016