GW1-2022-08466_Well Construction - GW1_20220420

Print Form;: ` ';
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14i WATER-ZONEs
FROM ITO DESCRIPTION
Well Contractor Name
260 ft- 325 ft• erw
4449-A ft ft.
NC Well Contractor Certification Number - "
15:'OUTER:GA511VG.for mold-casedlvvelts OR IINER ifa` ]tca6le ;
Rowan Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
p & 143 H• 61/4 m' SOR21 PVC
Company Name
46:INNER`CASIhICrUR`TUBING"e6thermaliclo9ed Ioo :'
2.Well Construction Permit#:366671 FROM TO DIAMETER THICKNESS IA MATERL
List all applicable well construction permits ri.e.WC,County,State,Variance,eta) ft ft to
3.Well Use(check well use).* n ft nL
Water SuPP1Y Well: FROM EEN
TO s DLY.IIETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural [3Municipal/Public % ft in.
Geothermal(HeatinglCooling Supply) Residential Water Supply(single) ft ft to
Industrial/Commercial Residential Water Supply shared 18.GROUT
hTl ation FROM TO MATERIAL - E.MPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D % Y1 ft Holeplug Gravity 29 bags
Monitoring Recovery ft ft.
Injection Well: ft. ft.
Aquifer Recharge ElGroundwaterRemediation 19:8AND/GRAVELEACK ifa"llcable
Aquifer.Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
:]Aquifer Test . ostormwater Drainage ft. ft.
Experimental Technology n Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer ;30:DRii I ING'l oG uttacb aadiiion 4stxces fdecess -
FROM 70 DESCRIPTION color,hudn soigrock ram eta .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks 0 R. 20 ft• Clay
4.Date Welt(s)Completed:3f7/22 Well ID#366671 20 133 ft. Sandy day/overburden
5a.Well Location: ix, R 143 f`- Solid Rock
Jesus Trujillo ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
R• it
2875 Back Creek Church Rd, Mt Ulla 28125 ft ft.
Physical Address,City,and Zip
Rowan 522 166 31[`REtxARKS::': v
County Parcel Identification No.(PIN) -
+,�f�%A.i.,.:a.`w. mot'->•_�.'.^. k•t .r. .
56.Latitude and longitude in degrecs/tninutes/seconds or decimal degrees: ra:r ii;'.ri4''t#tt,� .i;iy;,�.�;;,,.;:y�j„+1
(ifwell field,one latilong is sufficient) 22.Certification:
35 39 25,745 N 80 43 2.092 W 3 ['2 (Z-Z
6.Is(are)the weli(s)Ox Permanent or Temporary Si—gnatfire ofCertified Well Contractor Date
By signing Otis form,I hereby cerilfy that the uell(s)rras(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EINo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to lire well owner.
repair wider'P21 remarks section or on.the back ofthisform. 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 details. You may also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:. 325 (fl•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmltlple uvells list all depths Ifdifferent(example-3 a1200'and 2©100) construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If nvtter level isabove casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (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 puck 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) 8 Method of test: airlift 24c.For Water Suably&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine Amount 15 oz completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016