GW1-2023-00461_Well Construction - GW1_20230109

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WELL CONSTRUCTION RECORD.(GW-1) For Internal Use Only:
L Well Contractor Information:
Spencer Adams 14;WATEIzzoN>as F.
Well Contractor Name ' F �^ �'' FROM TO I DESCPIMON
4449/� ,, ;lbyy �` '' " 80 ft. 200 ft-
-_
JAN 0 9 2023 200 ft. 34s % '�'
NC Well Contractor Certification Number 1S;;OUTE1tCASING foimuth caseJwciis,OR LDYER`da"'lica6le. .
Rowan Well Drilling s FROM To t nfln►Em mcwass IMATER1ar
r,- 0 ft. 80 ft. 6114 ur, SDR21 PVC
Company Name „`0i :'t6 INNERGASRVG UR[YlBI NG` eotbermtal'dosed-loo'
311980 � �
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERGIL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ..:..,.. _...:
FROM I TO I DIAMETER I SLOT SIZE THICE ESS I MA7ERIAL
Agricultural ©MunicipaUPublic ft, 1L in,
Geothermal(HeaAng/Cooling Supply) EIResidential Water Supply(single) ft. in
Ind usirial/Commercial OResidential Water Supply(shared) fL
18:GROUT
Im ati0m FROM I TO MATERIAL EMPLACEb1ENT ME77IOD&AMOUN
Non-Water Supply Well: 0 % 20 ft• Holeplug Gravity 31
Monitoring Recovery ft. [t.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19:tSAND/GRAVELTACK.sf a Gcable
Aquifer Storage and Recovery Salinity Barrier FROM TO 1. MATERIALI EbiP[ACEMENl brE[HOn
Aquifer Test 13StOrmwaterDrainage ft• it.
Experimental Technology [Subsidence Control fL ft.
Geothermal(Closed Loop) OTracer >20.-DRlLtING°)OC:atte'ckadditionelsbeetsif '"""
Geothermal(HeatinglCooling Return) nOther(explain under#21 Remarks) I FROM To I DESCRIPTION color,baWom soNroek n size.etc.)
0 ft 20ft Cray
4.Date Weil(s)Completed: Well Well ID#311980 20 ft: 60 ftSandy overburden
5a.Well Location: 60 fL 70 ft WeaUwed Rode
Comerstone III Properties 70 ft So fL SoHdRock
Facility/Owner Name Facility ID#(if applicable) 80 ft ,p ft Weathered brown veins
158 Lippard Springs Circle, Statesville 28677 ft. ft.
Physical Address,City,and Zip ft. ft
Iredell 4722665718 2r;RFIifARK4:-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/sceonds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
35 43 64.918 N 80 55 57.132 W
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6.ls(are)the weli(s)opermanent. or ElTemporary Signature ofCertiSed Well Contractor Date
� BY signing this form,I hereby,certify that the weR(s)was(were)constructed in accords
7.Is this a repair to an existing well: OYes or l�:1No with 13A NCAC 02C.0100 or 15ANCAC 02C.0100 Well Construction Standards and th
Ifthis is a repair.fill out known well construction information and explain the nature ofthe copy of this record has been provided to the Aoil owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
9.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
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; 345 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of i
For multiple wells list all depths tfdlJjerent(example-3 tCt 200'and 2®100) construction to the following:
10.Static water level below top of casing:30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6 010 24b.For Iniection Wells: In addition to sending the form to the address in
12.Well construction method:
rotary above,also submit one copy of this form within 30 days of completion of
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
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Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
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13s.Yield(gpm) 2 Method oftest:weir 24c.For Water Supply&Iniection Wells: 1n addition to sending the for.
the address(es) above, also submit one copy of this form wi
chlorine thin 30 day:
16 oz
13b.Disinfection type: Amount: completion of well construction to the county health department of the coi
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-:
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