GW1-2023-00445_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Az
Spencer Adams �4 waTER•zoNEs
FROM TO I DESCRI]MON
Well Contractor Name
133 ft 180 ft a°rM
4449 A 260 ft' 300 ft. 8GPM
NC Well Contractor Certification Number &OU:TERCASING'"ii1ti;40 4*0 ORIs1NER if ib IieaDle
Rowan Well Drilling FROM TO I THICKNESS I MATERIAL,
CompaoyName
0 It- 1 133 ft- 1 6114' in- SDR21 I PVC
r -
'16;:INNER`.CASINGOR>'TIIBING eotiiemrai doses=Too
2.Well Construction Permit#:Well-04-2022-169694 FROM TO DIAMETER THICKNESS `MATERIA
LW all applicable well construction permits(i.e.WC,County,Stare,Variance,eta) ft. ft. in,
3.Well Use(check well use): it ft in.
Water Supply Well: =�_,..
PP y FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
Agricultural ElMunicipaUPublic ft. ft in.
Geothermal(Heating/Cooling Supply) xMResidential Water Supply(single) ft. % is
Industrig(Commereial Residential Water Supply(shared) =1&'GROUT: _ }
kn ation FROM TO MATERIAL N EMPLACEMENT METHOD&AMOUNT
Non-Water Supp y Weil: o ft 20 ft Holep{ug Gravity 14 bags
Monitoring Recovery ft ft
Injection Well:•
ft. ft ,
Aquifer Recharge [3Groundwater'Remediation
r 19.SAND/GRAVEL PACK41f i6olksble
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft ft.
Experimental Technology Subsidence Control tt ft
Geothermal(Closed Loop) OTracer 30DR1II:ING;LOC aitact►aadit,oniiT'slieee4ifn"""'" "'
Geothermal Heatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION rotor,hardness,soiVrock {n size,eta
0 ft- ZO ft �y
4.Date Well(s)Completed: 12/16J22 Well ID#169694 20 ft 120 ft- sandy overburden
5a.Well Location: 'm & 123 ft we'atheredrock
Galloway Construction 123 K- 133 ft s°rd rock _
Facility/Owner Name Facili ID# if liable 140 it' "� ft soft rock
ty C aPP )
4970 Surfwood Dr, Sher'rills Ford 28673 n• ft
Physical Address,City,and Zip ft ft
2023
Catawba 460604835899 ItREMARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees-
(ifwell field,one lattlong is sufficient) 22. rtirieation: II
80 5919.647
35 33 29.072 N
6.Is(are)the well(s)OX Permament or OTemporary SignatureofCertified Well Contractor Date
By.signing this form,I hereby certfy 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 15,4 NCAC 02C.0200 Well Construction Standards and that a
)this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or an 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 ofwells 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 llf&fjerent(example-3 200 and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft) Division of water,Resources,Information)Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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 Setwlce Center,Raleigh.NC 276994636
13a.Yield(gpm) 12 Method of test: weir 24c.For Water Supply&Infection 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: 14 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