GW1-2023-00469_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GMI-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14;,WATERZOINES-
Well Contractor Name FRO&I I TO DESCRIPTION
35 ft. 360 ft-
4449-A ft. ft.
NC Well Contractor Certification Number i"
Rowan Well Drilling FROM TO I DIAMETER THICKNESS MATERIAL I
0 ft, 35 ft. 6 114 SDR21 PVC
Company Name
ING(geotbefidat
2.Well Construction Permit#:312721 FROM TO DL"ZTER in. I THICKNESS MATERIAL
List all applicable well construction permits ft.e-07C,County State,Variance,, it. ft.
& in.
3.Well Use(check well use):
.........
7777
ater-Supply Well: FROM TO DMIMETER SLOT SIZE THICKNESS MATERUL
Agricultural Mmunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) ffiResidential Water Supply(single) ft, ft, in.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MAURLAL EMPLACEMENT METHOD&AmouNr
Non-Water Supply Well: a ft- 20 ft. Holeplug Gravity 14 bap
73monitoring 13Recovery ft. ft.
Injection Well: ft.
:)Aquifer Recharge OGroundwaterRemediation
'PAC, XGU6011cablel,.19.SAND GRAVEL
Aquifer Storage and Recovery [)Salinity Barrier TO L, MATERIAL 1ACEMENT METHOD
Aquifer Test DStormwatcr Drainage ft. ft.
Experimental Technology OSubsidence Control ft.
Geothermal(Closed Loop) 13Tracer ­211,1DRILl 5INC.LOG tattach iddidmintsbeetif MiMkWW�t;
Geothermal(Heating(pooling Return) nOther(explain under#21 Remarks) I FiioDf TO DESCRIMON(color,tim-tints%soiVirocktype size.etc.)
0 ft- 3 ft- clay I I
4.Date Well(s)Completed*12/5/22 Well ID#312721 3 ft. 14 fL Sandy,Rock
5a.Well Location: 14 & 21 % Sandy Overburden
Cydney Olea 21 ft. 1 35 ft- Solid Rock
Facility/Owner Name Facility IDN(if applicable) 42.0 ft. soft Vein
324 Paftemote Rd, Mooresville 28117 58 "t- 60 S Ct
oftVein
L_ ftt a- V" LJ
Physical Address;City,and Zip ft. ft
T
Iredell 4637 30 6503
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(ifwell field,one latfiong is sufficient) 22.Certification:
35 34 39.996 N 80 54 17.139 W 4511A� -11
6.is(are)the well(s)OPermanent or 13Temporary Signatdre of Certified Well Contractor, Date
By signing this form,I hereby certify;Brat the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or MNo with IJA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,.fill out known well construction information and explain the nature of the copy of thus record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional vMl 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 details. You may alio attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of'wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: 605 00 24a. For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths#7dffferezrl(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Reiources,Information Processing Unit,
If water level is above casing use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 11
—(in.) 74b.For Infection 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. 1
(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(gpim) 4 Method of test:weir 24c.For Water it—U,2. 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: 1.8 lbs 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 ResourceI s Revised 2-22-2016
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