GW1-2022-08457_Well Construction - GW1_20220420

Prinf Form �.
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 260 ft- 305 ft rzcvH
ft &
NC Well Contractor Certification Number <''15.'OUPER CASING;far multi-ciii Bd.wells OR"LINER•if a licable
Rowan Well Drilling FROM TO DIAMETER THICKNESSI MATERIAL
Company Name 0 ft 113 ft' 6 1/4 m' SDR 21 PVC
366960 16:1NNER CASINGiOR'TUBING eothermal closed loo` r
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.WC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
Agricultural QMunicipal/Public M & in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft in
IndustriaUCommercial []Residential Water Supply(shared) 1&GROUP
hri ation FROM TO« MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft Holeplug Gravity 9 bags
Monitoring Recovery ft. ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
=79.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) Tracer a-20.:DRIILINGLOG attach Additional sheets if necessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiFroek s' eta
0 ft. 20 ft Clay
4.Date Well(s)Completed:3/28/22 Well EN 366960 20 ft 76 ft Clay/Sand
5a.Well Location: ,a ft. 103 ft. Weathered Rock
Martha Lloyd 103 ft 113 ft Solid Rock
Facility/Owner Name Facility ID#(if applicable) 116 ft ++e ft. Vein/dirty,,__,
2665 Baker Mill Rd, Cleveland 27013 % ft ,
Physical Address,City,and Zip
ft ft' R 2 0 20
Rowan 724 005 '`21•REMARKS;'.
County Parcel Identification No.(PIN) -
,,.7�j.: '���:..u,is i"•,.'�.1..•�:':� i— .i.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
35 47 43.253 N 80 40 35.171 W
3 tz s' l z�
6.Is(are)the well(s) _Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(ivere)constructed in accordance
7.Is this a repair to an existing well: [3Yes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 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: 305 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdierent(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 YL) 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.) 24b.For Injection 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 276994636
13a.Yield(gpm) 12 Method of test: Airlift 24c.For Water Supply&Injection 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: 14 ®z 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