GW1-2022-00189_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Spencer Adams
Well Contractor Name ' FROM TO DESCRIPTION
� 45 445 &ft� r.s cvnr
4449-A U r L 1 G:'zozz 1
NC Well Contractor Certification Number r s•
Ir1+J+-f:1,;C1 ?rt v�?,tifi l,r5a s15.0UTER"CASING for'multr-eased;w'e1Ls:OR'LINEk,Mi bablef'
Rowan Well Drilling ej�'r�1 sw{� FROM TO DIAMETER THICICMS MATERIAL^
Company Name 0 ft. 145 ft' 61/4 1 m. SDR21 PVC
AP-320676 :16 INNER;CASING,OR`--TUBING!(66thei�mal'closed=loa"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft. ft. 1O
3.Well Use(check well use): fL & in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. g. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial []Residential Water Supply(shared)
18`GROUT&_
Irri won FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation 191:SAND/GRAVEL PACK if a""liable ,,,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
I '
Geothermal(Closed Loop) Tracer '120 DRILL'INGLOG attacti.additionalsheets if necess9`
FROM TO DESCRIPTION color hardness soitfrock a 'n size,eta
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) o ft. 20 ft- day I
4.Date Well(s)Completed: 11/22/22 Well ID#AP-320676 20 ft, 130 ft,
sandy overburden
5a.Well Location: 130 ft. 145 ft. solid rock
Thomas Mahala 145 ft- 260 ft- soft gray/beige rock
Facility/Owner Name Facility ID#(if applicable) 260 ft. 445 ft. soft grey rock
1553 Ostwalt Amity Rd, Cleveland 27013 ft. ft.
Physical Address,City,and Zip
Iredell 4771 33 8634 =21::RES ARKS"t R.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
35 41 52.736 N 80 46 20.105 `l, / OLL
6.Is(are)the we0(s)O—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: E3Yes or XJNo 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 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-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: 445 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following: i
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 additi}n 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 276994636
(gp ) 1.5 air lift 24c.For Water Suaaly&Iniection Wells: In addition to sending the form to
13a.Yield m Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: 21 oz 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