GW1-2022-08421_Well Construction - GW1_20220420

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WELL CONSTRUCTION RECORD(GW-1) r
r Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14:WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
4449-A 78 ft- 290 it. zar.,
$65it• aes ft.
NC Well Contractor Certification Number 75'OUTER CASING for riiiilh casedwells QR LINER;ifa' hcable ':
Rowan Well Drilling FRO51 TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 78 ft. 6114 1m SDR21 PVC
16 INNER CASING`OR:TUHING eothetuial closed'loti
2.Well Construction Permit#:352750 FROM TO DIAMETER I THICKNESS ._ MATERIAL
List all applicable well constrnetian permits(i.e.VIC,County,State,Variance,etc.) ft. ft in
3.Well Use(check well use): ft.
Water Supply Well: 17.:SCREEN
FROM To DIAMETER SLOT SIZE THICENESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EX Residential Water Supply(single) iL ft is
bldustriaUCommercial Residential Water Supply(shared) 1&.GROUP
furl ation FROM TO .MATERIAL IEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity
Monitoring Recovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge n0roundwater Remediation
19.:SANDIGRAVEVPACK'ifa 'licable '
.Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage ft. ft.
Experimental Technology 13Subsidence Control B. ft.
Geothermal(Closed Loop) Tracer -20.-DRILLING LOG attach additional shttts`if'necessa
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FRoMI TO DESCRIPTION(color,hadaess,soalro k b2e,grain sim,etc.,
0 ft. 20 ft Clay/Sand
4.Date Well(s)Completed:3/16/22 Well ID#352750 20 ft. ea ft. Weathered Roar
Sa.Well Location: os ft. 78 ft. Solid Rock
Gary &Lorie Beale ft. ft
Facility/Owner Name Facility to#(ifappficable) ft. fL
295 Morgan Rd, Gold Hill ft. ft.
Physical Address,City,and Zip ft, & App
n
Rowan 539 076 21:REMARKS'
County Parcel Identification No.(PIN)
.7,•1,�V-;jar_,•` 1)it!.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ..
(if well field,one lat/long is sufficient) 22.Certification:
35 31 58.545 N 80119 53.327 W
6.Is(are)the well(s)ox Permanent or OTemporary Signs ure of Certified Well Contractor Date
By signing this form,I hereby cerl fy that the ivell(s)was(irere)constructed in accordmice
7.Is this a repair to an existing well: [3Yes or E)No Willi 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a
If thly is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis f6rin.
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 1 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: 485 (f1.) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: (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
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) 3.5 Method of test: weir 24c.For Water Stu my&Infection 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 22 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