GW1-2022-08442_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only-
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449 A 79 ft- 405 ft. ,a reM
ft. ft.
NC Well Contractor Certification Number 15;.OUTER CASING for multi-cased wells OR LINER if a 6c2bie
Rowan Well Drilling FRObI TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 79 ft, 6114 in• SDR211 PVC
3264H 16.INNER CASING OR TUBING eothermal closed-moo
2.Well Construction Permit#' FROM TO DIANIL:TER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
�'Vater Supply Well: 17.SCREEN
_ FROM TO DI�11WJTERSLOT SIZE THICKNESS INMTERiAL
HAgricultural ©Municipal/Public ft. ft.Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft.
IndustriaVCotnmercial OResidential Water Supply(shared) 18.GROUT
' Iffigation FROM TO DiATERLIL EDIPLACEMENT METHOD&AMOUriT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 20 bags
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I- Aquifer Storage and Recovery OSalinity Barrier FROM to MATERIAL I EMPLACV%imr METHOD
_ Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) CiTracer 20.DRILLING LOG attach additional iheets if 6ecessa
Geothermal(Heating/Cooling Return) 'Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type rain size,etc.)
0 ft. 10 ft, clay
4.Date Wells Completed: 7/14/22 Well ID#32648 10 ft. 50 ft'() p sandy overburden
5a.Well Location: so ft. 69 ft. weathered rock
Angelis Smith 69 ft. 79 ft, solid rock ,-
wn ft. tt. 4. 'k..
Facility/Owner Name Facility MH(if applicable) —L
2570 Potneck Rd, Woodleaf 27054 ft. ft. AUG .9
Physical Address,City,and Zip ft. ft.
Rowan 808 022
21.REMARKS. r,�uts:�x.:• i w.S;�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification;
35 46 8.837 N 80 32 55.278 W
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor, Date
By signing this form,i hereby certify that the well(s)was(svere)constructed in accordance
7.Is this a repair to an existing well: [3Yes or IX,No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
lfthis is a repair,fill out known well constnuction information and erplain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of 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 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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths ifdifferent(example-3« 00'and 2 a 100') construction t0 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
I I.Borehole diameter: 6 (in.) 24b.For Inieetion 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) 1/2 Method of test: Weir 24c.For Water Supply&Inieetion Wells: 1.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: 19oz completion of well construction;to the county health department of the county
where constructed.
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Form GW-I North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016
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