GW1-2022-09347_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO I DESCRDPTION
4449-A 182 rt- 2e5
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER'if a 'li ble
Rowan Well Dulling FRONT TO DIAMETER I THICKNESS MATERIAL
0 ft. t82 ft. 6114; in- SDR21 PVC
Company Name 16.INNER CASING OR TUBING eoihermat dosed-loo
Z.Well Construction Permit#: 13858 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LIIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 47.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural DMunicipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) KIResidential Water Supply(single)
_ fL ft,
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holeplug Gravity 15 bags
Monitoring [ Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
� Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft- ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTraccr 20.DRILLING LOG attach additional sheets if necessary).'
Geothermal(Heating(Cooling Return) MOther(explain under#21 Remarks) I FROM To DESCRIPTION color,hardness,soiUirock type rain size,etc.
0 ft. t2 ft. Clay
4.Date Wells Completed:9(5/22 Well ID#13858 12 ft. 172 ft.
P SandylOverburden
5a.Well Location: in ft. 182 ft. solid Rock
Cornerstone III Properties 183 ft- 2E5 ft- Brown'Soft Rock
Facility/Owner Name Facility IDif(ifapplicable) ft. ft.
5104 Kings Pinnacle Dr, Kings Mtn ft. ft.
Physical Address,City,and Zip
It. ft. T
Gaston 3513 01 8896 21.REMARKs
County Parcel Identification No.(PIN) Ir r.- _`'' `t„�,,.s�:�a� . � tlr;i!
a`'`a�_!ira:v`L;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertilication:
35 11 22.876 N 81 18 25.057 W
6.Islam)the well(s)Ex Permanent or OTemporary Signature bfCertified Well Contractor Date
By signing this farm,1 hereby certify;hat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• [3Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 01C,0200 Well Construction Standards and that a
I(this is a repair,fill out known well construction information and explain the nature ofthe copy of this retard has beenprovided to the well owner.
repair under#21 remarks section or on the back of this torn.
23.Site diagram or additional well details:
8.For Geoprobc/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 OW-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: 285 Ut-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (€t.) Division of Water Resources,Information Processing Unit,
If rater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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
i
13a.Yield(gpm) 7 Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 13 oz
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: . Amount: 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
I.