GW1-2022-08479_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 87 ft. 300 ft.
h GFm 1
420 ft. 450 ft. 70 GRA
NC Well Contractor Certification Number .15...OUTER CASING for inoltr-cusw..wells 9R'LINER if a" licable '
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
p ft. 87 ft. 61/4 in• SDR21 PVC
Company Name
366669 16.INNER CASING OR. UBING eothermal closed-loop)
2.Well Construction Permit#• FROM To DIAMETER I THICKNESS I AIATERrAL
List all applicable well const7iction penults(i.e.UIC.County,State,l'ariance,etc.) rt. ft. in.
3.Well Use(check well use): ft. ft. in.
17;SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS DATERIAL
Agricultural OMtmicipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) pResidential Water Supply(single) g, ft.
IndustriaUCommercial DResidential Water Supply(shared) Ig,`GROL'T:
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0 ft. 20 ft. HOleplug Gravity 12 bags
_ Monitoring }Recovery ft. ft.
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a lieable "
I Aquifer Storage and Recovery CJSalinity Barrier FROM TO MATERIAL I E\rPLACEMENT METHOD
Aquifer Test OStormwater Drainage it. ft.
i-Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer ..20:DRILLING-LOG attachadditioritil'sheetsiftikessa
FROM TO DESCRIPTION(color,hardness,soil/rock y e, min size,eta
Geothermal(Heating/Coolin Retum) i Other(explain under#21 Remazks)
0 ft. 20 ft• Clay I Sand
4.Date Wells Completed: 7/11/22 'Well iD#366669 20 ft. 45 ft.
p Sandy Overburden
5a.Well Location: 45 ft. 77 ft. Weathered Rock
Chris Terry 77 ft. 87 ft. Solid Rock
Facility/Owner Name Facility IDH(if applicable) 87 ft• 105 ft. Intermittent Brorm Veins
11185 Cool Springs Rd, Woodleaf ft.
Physical Address,City,and Zip ft. ft. "
Rowan 811 049 21 RE vIARKS" AUE2
County Parcel Identification No.(PIN) - - --
-�•f^``il r*. .... .,,..er lei
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one W/long is sufftcieot) 22.Certification:
35 47 8.197 N 80 37 0.686 W zz
6.is(are)the well(s)iX Permanent or OTemporary Signature of Certified Well Contractor Date
llv signing this form,I hereby certify that the u•ell(s)eras(were)constructed in accordance
7.Is this a repair to an existing well. OYes or DNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Wc1l Constriction Standards and that a
If this is a repair•fill out Anown well constriction information and erplain the nature of tile copy of this record has peen provided to the well owner.
repair raider P21 reatarks•.section or on the back ofthr c 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 I 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: 485 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
i,or multiple wells list all depths if different(aranhple-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing:40 (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.) 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) 71 Method of test: Weir 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: zz oz completion of well constructiau Ito the county health department of the county
where constructed.
I
Fonn GW-1 North Carolina.DepartmentofEnvironmental Quality-Division of water Resources Revised 2-22-20I6