GW1-2022-09699_Well Construction - GW1_20220420

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
1.Well Contractor Information:
Spencer Adams 14.WATERZONES
FROM TO I DESCRIPTION
Well Contractor Name 73 ft- 405 it.
4449-A
ft. f,
NC Well Contractor Certification Number
15.:OUTER CASING:for utti id,nellsl'%I"WEJNER ilr Lapqllcable)�:
Rowan Well Drilling FROM TODIAMETER MATERIAL
Company Name 0 ft- 73 ft- 6 1/4.. '- I SDR21 PVC
16.INNER CASING-OR TUBING(00berutid tWed-looril
322592 FROM. TO DIAMETERI THICKNESS MATERIAL
2.Well Construction Permit H;
List all applicable it-ell construction permits(i.e.UIC,Coun%State,Variance,etc.) ft. ft.
In
3,Well Use(check well use): ft ft. in.
Water Supply Well: IT SCREEN
FROM TO DIA31ETER SLOT SIZE THICKNESS MATERIAL
"lAgricultural 0Municipal/Public ft. ft. in.
"IGeothermal(Heating/Cooling Supply) Ex Residential Water Supply(single) & ft. in
:IIndustrial/Commercial E)Rcsidential Water Supply(shared) :.It GROUt,4
nkrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 8
:)Monitoring FIRecovery ft. ft.
Injection Well: ft. ft.
3Aquifer Recharge nGroundwater Rentediation
19.SAND/GRAVEL PACK(ifalitplicable)
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
—JAquifer Test OStormwater Drainage fr. ft
—)Experimental Technology ElSubsidence Control ft. ft.
:.IGeothermal(Closed Loop) DTracer 20.DR]ILLING LOG(attach:additional sh6iti
—IGeothermal(Heating(Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardrims,sttillmktype,grain s im%etc)
0 ft- 23 ft- Red Clay
3/24/22 322592 ft.
4.Date Well(s)Completed:_Well IDN 23 63 Sandy Overburden
5a.Well Location: ft. 73 ft. Solid Rork
Jeff Morrison ft. ft.
Facility/Ovimer Name Facility ID.#(ifapplicable) ft. ft.
127 Hudspeth Rd, Statesville 28677 ft. ft.
Physical Address,City',and Zip ft. ft.
Iredell 4720490193 ilsREntAwts
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell lichl,one latliong is sufficient) 22.Certification:
35 40 58.397 N 80 56 21.999 W -7 ki
I-
6.1s(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form I hereby certo that lite ivell(s)eras(were)constructed in accordance
7.Is this a repair to an existing well: nyes or EINo with 15A AICAC 02C.0100 or 15A AICAC 02C.0200 MY Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature offize copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back afthisfOrm. 23.Site diagram or additional well details:
8.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or Nvell
construction,only I G`W-I is needed. Indicate TOTAL NUMBER OfNvells construction details. You may also attach additional.pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (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 2@100) construction to the following:
10.Static water level below top of easing: 00 Division of Water Resources,information Processing Unit,
Ifipater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 .(jn.) 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.anger,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) 112 GPM Method of test:Airlift 24c.For Water Supply&Injection 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: 20 oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016