GW1-2022-09371_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
57 ft. 385 ff• k.s calk
4449-A
it. ft
NC Well Contractor Certification Number 15.OUTER CASING.for:multi6caset wells`OR LINER tf a"6cable "
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 1 57 ft' 6114 in' I SDR21 PVC 37802$ 16.INNER CASING OR TUBING. eotbermat closed=loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL .
List all applicable well construction permits(i.e.UIC,Cormt K State,Variance,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMUER SLOT SIZE TatcravEss MATERIAL
Agricultural OMunicipal/Public tt. R. io•
Geothermal(Heating/Cooling Supply) Mitesidential Water Supply(single) R• g io.
Industrial/Commercial Residential Water Supply(shared) GROUT'
18.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 R• Hoteplug Gravity?bags
Monitoring [.Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
LExperimental
er Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test OStormwater Drainage ft. ft.
Technology Subsidence Control H• ff
ermal(ClosedLoop) Tracer2&DRILLINOLOG attach additionalsheetsifnecessaFROM TO DESCRIPTION color hardness soil/rock in size,etc.ermal eatin Coolin Return Other a lain under#21 Remarks
o tt. 12 tt. clay
4.Date Weil(s)Completed:9127/22 Well ID#378028 12 ft. 30 ft• sandy overburden
30 ft. 57 Ito solid rock
Sa.Well Location:
Rebecca Flowe ft
ra
Facility/Owner Name Facility ID#(if applicable) R• ft.
2440 Lentz Rd, China Grove ft. ft.
77
Physical Address,City,and Zip ft. ft ID ,�,• +; .1 _
Rowan 127 066 2L REMARKS Z,
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, ertification:
35 33 2.348 N 80 32 47.903 W R 2-71 z z
6.Is(are)the weil(s)E)Permanent or OTTemporary Signature of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,iU 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 of this 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: 385 UP 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@l00') construction 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 4in.) 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
m 13a.Yield
(gp ) Method of test:
1.5 weir 24c.For Water SUDD Wells
Iv&Iniection : In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Chlorine Amount: 19 oz completion of well construction Ito the county health department of the county
where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc s