GW1-2023-00460_Well Construction - GW1_20230109

I
WELL CONSTRUCTION RECORD(G'W-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams :aa wAT RZONFs. _ . . .•,. :r_ .
Welt Contractor Name FROM TO DESCREMON
4449-A e2 fL ,0 it. ,sera
.g ft. it
kr It
NC Well Contractor Certification Number i, S z � a 15 Ot71LIlCASING fortnWd=ease&wells aRI2NER t[a` U' b►e
Rowan Well Drilling II - FROM TO DIAMETER THICENESS MATERIAL
1 A W 9022 b fA 62 it• 61/4 in. SDR21 Pvc
CompmyName
16€INNER:GA51NG0lt TUBllWG` thernialclosetToo
2.Well Construction Permit#•311964 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable welt construction permits(i.e.WC.County,State,irdritiit e, ra.'J-" it. ft. L in.
3.Well Use(cheekweli use): it: ft. �.
Water Supply Well: 47.S ICREEi!T p _ DIA 1rLTER SLOT SIZE I THICKNESS MATERIAL
Agricultural OMunicipaWubiic & ft. in.
Geothermal(Heating/Cobling Supply) xMResidential Water Supply(single) R, ft. in.
Industriakommercial 13Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 k. Holeplug Gravity
Monitoring 13Recovery ft. fL
Injection Well:'
in ft
Aquifer Recharge Groundwater Remediation
`a9:'.SA�7GRA `PACK tfa""Ucable ._ `
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I E!ffLACEMENTMM0D
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13TTacer Za.DRILIiING.T oCr emcti'-additiorietstieets ifn "
FROM TO DESCRIPTION(color, es harda soivrock a sim etc.
Geothermal Conl
eatin in Return) Other lain under#21 Remarks o ft. 20 ft. Clay
4.Date Well(s)Completed:12/21/22 Well ID#311964 20 ft- eo ft.
Ssruty Ovardtrden
1.
5a..Well Location: w % 72 R' Quartz
Comerstone III Properties 72 ft- 82 ft Solid Rack
Facility/Owner Name Facility ID#(if applicable) ft. ft.
162 Lippard Springs Circle, Statesville 28677 ft. ft.
Pbysical Address,City,and zip ft. ft.
Iredell 4722666880 ZL REMARKS ,
County Parcel ldemification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long isstttyicient) 22.Certification:
35 43 54.882 N 80 55 55 W A4,4--
t 2[zi lZy
6.Is(are)the well(S)OPermanent or Temporary
Signature.of Certified Well Contractor Date
By signing this form,I hereby cerio that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EINo with 15A NCAC 02C,0100 or 15A NCAC 02C.0200 Well Construction Standards mud that a
Ifthis is.a repair•fall out known well aonsimcnan information and explain the nature ofthe copy oflhis record has been provided to the well owner.
repair under#21 remarks section or on the back o/'thisform, ,
23.Site diagram or additional well details:
S.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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferent(example-3@200'and 2@1005 construction to the following: is
10.Static water level below top of casing:25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servl ce Center,Raleigh,NC 276994617
11.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 forms within 30 days of completion of well
12.Well construction method: rotary construction to the.following: i
(i.e.auger,rotary,cable,direct push,etc.) I,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
P
13a.Yield(gpm) 1'S Method of test:Wert 24c.For Water Suppply&lWection Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
chlorine 19 oz completion of well construction to the county health department of the
13b.Disinfection type: Amount: P � � tY eP county
where constructed.
Form 6W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016