GW1-2022-09350_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 DESCRIPTION
4449-A
200 Cl- 245 ft.
ft, ft.
NC Well Contractor Certification Number 15.OUTER CASING tot multi-cased wells'OR LINER if a ticable '
Rowan Well Drilling FROM TO DIAMETER THICK'ESS MATERIAL
0 ft' 51 ft 6114 j in-
Company Name SDR21 PVC
13650 16.INNER CASING OR TUBiNG igeotherma]closed-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable imll construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: I7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaVPublic ft. ft. in.
Geothermal(Heating(Cooling Supply) XiResidential Water Supply(single) g ft in.
Industrial/Commercial OResidential Water Supply(shared) 1S GROUT
h ri ation FROM TO MATERIAL EMPLACEMENT AIETHOD&AMOUNT
Non-Water Supply Well: o B• 20 h• Holepwg Gravity 6
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge nGroundwater Remediation 19.SAND/GRA*TLPAGK if a livable
r Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG faffacb additional-sheets if necessa
FROM TO DESCRIPTION color,hardness,soil/rack: a min.size,etc.
Geothermal(Heating/Cooling Return) >Other(explain under#21 Remarks 0 tt. 73 ft. elay '
4.Date Wells Completed:8/25/22 Well ID#13650 13 ft. 34 ft. Sandy Overburden/weathered rocj
5a.Well Location: 34 ft. 51 R' Solid Rod*
Cornerstone III Properties 55 ft. so B* Brown Rock
Facility/Owner Name Facility ID#(if applicable) 155 ft +es ft Brown Rode
5004 Kings Pinnacle Dr, Kings Mtn 28086 2301 245 ft. Brown Rock
Physical Address,City,and Zip ft. ft. "^s
Gaston 3513 00 7945 21.REMARKS OrT
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertillcati0n:
3511 13.940 N 81 18 26.717 W
6.ls(are)the well(s)�Permanent or Temporary Signature of Certified well Contractor: Date 2
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or x)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/atown well construction information and explain rite nature of the copy of this record has been provided to the well owner.
repair under 4121 remarkv section or on the back o(this form.
23.Site diagram or additional well details:
S.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-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: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierernl(example-3@200'and 2 a 100) construction t0 the following:
10.Static water level below top of casing: 30 (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 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 276994636
i �
13a.Yield(gpm) 20 Method of test: Airlift 24c.For Water SIIDDIV&Iniection Wells: In addition to sending the form to
the address(es) above, also submit 4one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: t4 oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016