GW1-2022-09356_Well Construction - GW1_20221010

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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 300 ft• 325 ft. 17 GPM
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LfIVER if a liable
Rowan Well Drilling FROM TO DIAMIETER T}HCKNESS MATERIAL
Company Name p ft. 70 ft 61t4 in. SDR21 PVC
327042 16.INNER CASING OR TUBING 6feothermat closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERLtL
List all applicable well construction permits(i.e.(11C,County,Slate,Variance,etc) ft. ft. in.
3.Well Use(check well use): tt. ft. in
Water Supply Well: 17,SCREEN_<
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic ft ft. in.
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft. ft. 'in.
industrial/Commercial OResidential Water Supply(shared) I$GROUT
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft. Holeplug Gravity 33 bags
Monitoring ORecovery
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a 'liable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.'DRILLING'LOG"attach additional sbeets if necessa`
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfroek in size,etc.
0 ft. 19 ft* Red Clay
4.Date Wells Completed:8/19/22 Well ID#327042 79 ft. 42 ft.
() Pleted: Sandy Overburden
5a.Well Location: a ft. 70 ft• Solid Rock
Caruso Homes ft. ft.
Facility/Owner Name Facility IDS(if applicable) ft. ft.
726 Wiggins Rd, Mooresville ft.
Physical Address,City,and Zip
ft. ft.
Iredell 4678 21 7627 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C reification:
35 36 40.914 N 80 46 22.096 W
8 �, y �Zz
6.Is(are)the well(s)�c Permanent or -Temporary Signature o Certified Well Contractor Date
By signing this form.I hereby eertify;that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or E)No with 15A NCAC 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 record has been provided to the well owner.
repair under'21 remarks section or on the back gfthis 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 I GW-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: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100') constriction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water 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: constriction to the following:
(i.e.auger,rotary,able,direct push,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: weir 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
13b.Disinfection type: chlorine Amount: 15 oz completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016