GW1-2022-09353_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRD'TION
Well Contractor Name
4449-A 200 ft. 285 ft' 7SGPM L
k. k.
NC Well Contractor Certification Number 15.OUTER CASING'for multi cased wells OR LINER'if a Gcable
Rowan Well Drilling FROM TO DIAMETER THICKNESS 1fble) L
0 ft 120 ft 6114' in' SDR PVC
Company Name
13856 16.INNER CASING OR TUBING eotherm&I closed-loop)
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
Agricultural DMunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) k. ft.
IndustriaUCommercial Residential Water Supply{shared) 18.GROUT
lrri atlon FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft Holeplug Gravity
Monitoring _Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0oroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.'DRILLiNG LOG attach-additional sheets if necessa
HFROM TO DESCREPTION color,hardness soilfroek rain size,etc.
Geothermal(Heating/CoolingReturn) 'Other(explain under#21 Remarks)
0 ft. 10 ft• Red Clay
4.Date Well(s)Completed:8129/22 Well ID#13856 10 ft. 110 k.
SandyOvertumden
5a.Well Location: +ha ft. 120 ft. Solid Rods
Cornerstone III Properties 125 ft- 180 ft* Brown Rode
Facility/Owner Name Facility ID#(if applicable) 195 ft. 2M ft. Brown Rack k
5120 Kings Pinnacle Dr, Kings Mtn 28086 ft. ft.
Physical Address,City,and Zip ft. ft.
Gaston 3513 02 0313 21•REMARKS
County Parcel Identification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3511 25.183 N 81 18 29.169
6.is(are)the well(s)�X Permanent or Temporary Signature of Certified Well Contractor Date
By signing this fnrm,I hereby certify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: [3Yes or `x)No with 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this retord has been provided to the well owner.
repair under.421 remarks section or on the back ofthis 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 INSTRUCTIONS
9.Total well depth below land surface: 285 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:45 (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) 25 Method of test: Airlift 24c.For Water Supply&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 completion of well constructionito the coup health department of the coup
136.Disinfection type: Amount: p t t1' p n'
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016