GW1-2022-09374_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams ;44;WATER ZONES:-
Well Contractor Name FROM TO DESCRIPTION
4449-A 110 ft. 135 fL 2 GPM j
zoo ft* 305 fL 2 GPMNC Well Contractor Certification Number `�15.�OUTER CASING for'muIti4ssed.wells OR LINER'if a 'Gcable
Rowan Well Drilling FROM 1 TO I DIAMETER TffiCIINESS MATERIAL
Company Name
0 ft• 76 ft. 6114 in. SDR21 PVC 378718 :16:'l]VNER CASING OR TUBING eothermal"closed-loo` ` -,, ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LUC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): & ft. in.
Water Supply Well: ,;,41 SCREEN
FROM I TO , DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaUPublic ft. ft.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) fL fL in.
IndustriaUCommercial Residential Water Supply(shared)
_18:GROUT _
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 37 bags
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19:SANDlGRAYEL PACK if a 'liable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer "20."DRILLING LOG ittach additional sheets ifbecessa `
Geothermal Heatin C oling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiVroclitylie,grain size,etc
0 ft. 5 ft. Gay
4.Date Wells Completed:9/28/22 Well ID#378718 5 ft. 55 ft.
() p wetsandycay
5a.Well Location: s fL 66 fL unconsolidated rock
Jeremy Hardy 66 ft. 76 fL solid rock
Facility/Owner Name Facility ID#(if applicable)
125 Campbell Rd, Woodleaf
Physical Address,City,and Zip ft. ft 02Z
Rowan 8172008 '21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
35 45 11.426 N 80 34 5.430 W
6.Is(are)the weil(s) x Permanent or Temporary 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: ®Yes or IgNo 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 wider 421 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 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: 305 (ft-) 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 1Q100') 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 (in.) 24b.For Infection 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) 4 Method of test: welt 24c.For Water SumDly&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: laoz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i