GW1-2022-08396_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
SPENCER ADAMS 14WATERZONES',
Well Contractor Name FROM TO DESCRIPTION
4449-A 69 ft• 545 ft• t GPhf
ft_ it.
NC Nell Contractor Certification Number 15.OUTER'CASING for inblfi cascd'SVells OR LINER'if a livable
ROWAN WELL DRILLING FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 69 ft. 6114 in. SDR 21 PVC
2020-00003251 16.IN ANER C SING OR TUBING eotbcrural dosed-loop),
2.Well Construction Permit#:
FR01f TO DIAMETER TIiICIt:NFSS MATERIAL
List all applicable well construction permits r.e.UIC,County,Stale,Variance,eta) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: I7b SCREEN
FROM TO DIAMETER I SLOT SIZE I THHCKNESS I MATERIAL
_
Agricultural QMunicipal/Public 8. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft.
Industrial/Commercial OResidential Water Supply(shared)
_ 18.GROUT. .:. :.` ..
irrt ation FROM TO MAT ERLAL E IPLACEDIENT METHOD&AMOUNT
Non-Rater Supply Well: 0 ft- 21 ft• HOLEPLUG GRAVITY 8 BAGS
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19..SAND/GRAVEL PACK if a livable).
Aquifer Storage and Recovery OSalinily Barrier FROM To MATERIAL EMPLACEMEN"rMETHOD
Aquifer Test QlStormwater Drainage
f Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 1OTracer 20.-DRILLING LOG attach additional sheets ifiiecessa
Geothermal(Heating/Cooling Return) 'Other(explain under#21 Remarks) FROIII TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
0 ft. 10 ft. CLAY i SHALE
4.Date Wells 6/22/22 Well ID#202000003251 10 ft. 59 ft.
()Completed: SHALE/WEATHERED ROCK
5a.Well Location: so ft. 60 ft. SOLID ROCK
HOMES FOR THE TROOPS
Facility/Owner Name Facility lDO(if applicable) ft. ft.
2437 BEECHWOOD DR, ASHEBORO ft. ft. a
Physical Address,City,and Zip ft. ft.
RANDOLPH 21.REMARKS nv R�Q(
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22'C rtiFcation:
35 43 39.469 N, 79 53 26 W
4 122 �z�
6.ls(are)the wells) iX Permanent or OTemporary Signature of Certified Well Contractor Date
By sunning[Iris form,1 hereby certify that the rrell(s)ryas(is-ere)constructed in accordance
7.Is this a repair to an existing well: Oyes or ONO Will 15A NCAC 02C.0100 or 15A NCAC 02C_0200 1Vell Construction Srardartls,and that a
Ifthis is a repair,.flll out knon7n well construction information and explain the nature of the cop},of 1his record has been provided to Ilse well owner.
repair tinder 421 rennarkv section or on the back of thisfonn.
23.Site diagram or additional well.details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the stone 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: 545 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
Foraultiple ivelly list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241b.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
12.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) 1 Method of test:WEIR 24c.For Water SunDiv&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CHLORINE Amount: 25 OZ 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