GW1-2022-09351_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 100 ft. 225 ft. 2D r,,,,E
ft. tt. 4
NC Well Contractor CertificationNumber
15.OUTER CASING for multi-cased well§ OR LINER if a'licable
Rowan Well Drilling FR011i TO DIAMETER THICKNESS MATERIAL
0 ff 61 ft.
61/4 in' SDR21 PVC
Company Name
13694 16.INNER CASING OR TUBING other mat dosed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS _MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural DMunicipal/Public fL
Geothermal(Heating/Cooling Supply) EIRcsidential Water Supply(single)
:)Industrial/Commercial Residential Water Supply(shared) I8.;GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holepiug Gravity 12
Monitoring Recovery
Injection Well: ft. tt.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK:(iforlijlivable
I Aquifer Storage and Recovery Salinity Barrier FROM I To I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type.grain sae,etc.
0 ft. 12 ft. Clay
4.Date Wells Completed:8/26/22 Well 113694 12 ft. 35 ft.
P Sandy Overburden
5a.Well Location: 35 ft. 61 ft. Solid Rode
Cornerstone III Properties 62 ft. 785 fL [grown Rode _
Facility/Owner Name Facility ID# ifaPPlivable) 205 ft. us
Rock
-5008 Kings Pinnacle Dr, Kings Mtn 28086 ft. ft.
Physical Address,City,and Zip
ft. ft.
Gaston 3513 01 7162 21.REMARKS
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. erti$cation:
3511 15.045 N 81 18 26.202 �t
6.IS(are)the we0(s)oX Permanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(v)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or XJNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
f this is a repair,fill out known well canstnrction information and explain the nature of the copy of this record has been provided to the well owner,
repair under 121 remarks section or on the back ojthis 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL LNSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfferent(example-3@200'and 2@/00') 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 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) 20 Method of test: Airlift 24c.For Water SunDly&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 1 t oz completion of well construction 6 die coup health department of the county
13h.Disinfection type: . Amount: P county P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
l