GW1-2022-09349_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 DESCRIPTION
4449-A 225 ft• 265 ft. ,a GPM'
NC Well Contractor Certification Number 15.OUTER CASING 06r multi-cased wells OR LINER if a 6cable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name p ft. 183 fl- 1 6114 In SDR21 PVC
13697 16.INNER CASING OR TUBING eothernrat dosed4odol
2.Well Construction Permit#: FROM To I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.Carroty,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
"Agricultural DMunicipal/Public fL ft, in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft• k ;a
Industrial/Commercial OResidcmial Water Supply(shared) 18.GROUT`
Itli ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k• 20 ft• Hdeplug Gravity 42 nays
Monitoring 1311ccovery
Injection Well:
it. ft.
_
i Aquifer Recharge QGroundwater Remediation 19..SAND/GRAVEL'PACK ita 'Gcable
171 Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary).
Geothermal g ) ( FROM TO DESCRIPTION color,hardnes soilfrock a rain size etc.
(Heating/Cooling Coolin Retain — Other(explain under#21 Remarks
0 ft. 15 ft- Ctay
4.Date Well(s)Completed:9/15/22 Well ID#13697 15 ft. 173 ft. Sandy Overburden
Sa.Well Location: 173 ft' 163 ft' Soiid;Rock
Cornerstone III Properties 188 ft. 265 ft, Brown Soft Rode
Facility/Owner Name Facility IDtt(if applicable) ft. ft.
5016 Kings Pinnacle Dr, Kings Mtn
Physical Address,City,and Zip ft.
Gaston 3513 01 7590 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . L r i
(if well field,one lat/long is sufficient) 22.Certification-
35 11 18.885 N 81 18 25.518 9 1 ►S izz
6.Is(are)the well(s)ox Permanent or Temporary Signature of Certified well Contractor Date
By signing this form,I hereby certi,�i that the well(s)was(mere)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E)No with 15A AtCAC 02C.0100 or 15A NCAC 02C.0200 lyell Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided i to the well owner.
repair under#21 remarks section or on the back of this font.
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 l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also allach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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,hail Service'Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 18 Method of test: Airlift 24c.For Water Suonly&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: 12oz completion of well constructionko the county health department of the county
where constructed.
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Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016
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