GW1-2022-00190_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams i4:w�rER2oNEs,
Well Contractor Name . " FROif To I DESCRIMON
145 M85 lavM
4449-A D C 1 a 2022 ..
260 325 ft. 35 GPM ft. .
NC Well Contractor Certification Number = 15i.OUTER CASIL\G for.mnih�asid wells OR=LINER`.tta Gt ble
Rowan Well Drilling !n%Or—<z3!-_� ��;•c: ,; :3 Llr"g FRONT TO DIAMETER THICtQYESS MATERIAL
142 61/
ft. ft. in.
Company Name 0 4 SDR21 PVC
OS111/P-2022-3429 i16.INNEWCASING OR:. ING''eothermiii'dosed-lob.
2.Well Construction Permit#: FRONT TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in..
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :17 SCREEN <;.
FROM: TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public it.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared)
48.-GROUT
lrri ation FRONT . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fG Hoteplug Gravity 21 bags
Monitoring DRecovery it, ft.
Injection Well:
fL tL
Aquifer Recharge Doroundwater Remediation
19.SAND/GRAVELPACK ifa "Ncable
Aquifer Storage and Recovery OSalinity Barrier FROM TO NATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stotmwater Drainage ft. ft.
xperimental Technology Subsidence Control ft. %
Geothermal(Closed Loop) Tracer fo.-DRILLING'LOC. attach sddiiionnl'sheets ifuecessa''
Geothermal(HeatinglCooling Return) riOther(explain under#21 Remarks) FRONT TO DESCREMON color,hardness,saiVroch type,gmin si mete
0 ft- 15 fL Red clayl
4.Date Well(s)Completed. 11/14/22 Well ID#Oswp-2022-3429 15 ft, 132
ft—Sandy overtwrden
5a.Well Location: 132 ft. 142 ft' Solid Rock
Dean Powell It. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
166 Wiggins Rd, Mooresville 28115 ft. ft.
Physical Address,City,and Zip fL ft. !
Iredell 4679423069
21%REMARKS
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one lat/loug is sufficient) 22.Certification:
35 3819.701 N 80 46 9.009 WA i I S` zz.
Signature of Certified Well Contractor Date
6.Is(are)the well(s) Permanent orTeroporary
By signing this form,I hereby certify drat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XJNo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
Ifthis is a repair,fill out known well constriction 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:' SUBNMTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (it) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200 and 2WO) 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 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:
(Le.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) 4.5 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 they 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