GW1-2023-00463_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Informations
i
Spencer Adams 14.WATERZONES ' . ..>, i -`-
Well Contractor Name -
tr-•= --,. FROM TO DESCRUMON
,��El�'� - `?. ( z,.,� ", 605, it.
4.,,. 74 ft inePM
4449 A ��ty fr. ft.
NC Well Contractor Certification Number JAN ® 4 2023 1s 011TER:('ASING form�ldca"seiliveil§'ORLINER ifa Lcable
Rowan Well Drilling , r,� a FROM TO DIAMETER THICKNESS MnTERrai
,n4 r :�.,,... t�rlil
rqc+ 0 ft. 74 ft- 61/41 in- SDR21 PVC
Company Name
312000 16-MNER CASING,oR:TUBING "eotheiDial closed-lop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL-
List all applicable well construction permits 0 e.U1C,County,State,Yanance,etc.) ft- ft. in
ft. ft,
3.Well Use(check well use):
!7 SCREEN
Water Supply Well: FROM i TO I DIAMETER I SLOTSIZE THICKNESS` I MATERIAL
Agricultural [3Municipal/Public fL ft. lia
Geothermal(13eating/Co6ling Supply) EIResidential Water Supply(single) {t• ft. i in
Industrial/Coinmercial DResidential Water Supply(shared)
Irrigation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft' Holeplug Gravity 14 bags
Monitoring DReCIDYCry ft. it.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
lSAND/GRAVEL PACK if a"likable
Aquifer Storage and Recovery Salinity Barrier FROM I To MATERIAL EMPLACEMENT METHOD
Aquifer Test [39tormwaterDrainage it. ft. it
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -20.DRII LUNG-:LOG`'attach addiitionalsbi dts fneeessa
FROM TO DESCRIPTION color,hardness su tack size,Nu
Geothermal eating/Coolin Return Other(explain under#21 Remarks) 0 ft, 20 It. day h
12/29/22 312000 ft. ft.
4.Date Well(s)Completed: Well ID# 20 sandy overburden
5a.Well Location: 5o & 64 N' weathered rock
Comerstone III Properties 64 ft. 74 ft, solid rock
Facility/Owner Name Facility IDff(if applicable) ft. ft.
225 Lippard Springs Circle, Statesville ft. ft.
Physical Address,City,and Zip
ft. ft.
Iredell 4722672474 21:+REMARI{s;;
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(if well field,one lat4ong is sufficient) 22, ert�cation:
35 44 0.858 N 80 55 59.134 W
6.Is(am)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the a'ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or JMNo with ISA 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 921 remarks section or on the back of thisform. 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: 605 (W 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths ifdierent(example-3@200'aMd 2@100) construction to the following:
10.Static water level below top of casing: VW Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servi'Center,Raleigh,NC Z76994617
11.Borehole diameter: 6 (in.) 24b.For Injection 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.Nell construction method: rotary 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 27699-1636
13a.Yield(gpm) 1/2 Method of test:.weir 24c.For Water SUDDIV&Injection 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: 1,71bs completion of well construction to the county health department of the county
where constructed.
Frtnn CiW-1
North Carolina Department of Environmental Quality-Division of Water Resources,ces Revised 2-22-2016
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