GW1-2023-00470_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GW-11 For Intemal Use Only:
1.Well Contractor Information: A"
Spencer Adams 14_wATER20lvFs
Well Contractor Name s FROM To DESCRIPTION
4449-A _ f: '` 84 ft. 180 ft. 3 GM
�'�.�...,�':� ...i',°.� dam P?.:.,+�
180 ft. 240 ft. 7 OPM�
NC Well Contractor Certification Number J A . O Q 23 15:.tlUTER CASllVG for mul6aened wells';OR LINER rf:a'lieabte .:..
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name o ft. 84 ft. 61/4 in- 0.185 Galvanized
e'6-'30G 16 I MR:GASINGORTIIBING' 'eothermalclosed�loo
2.Well Construction Permit#:OSWP ZOZZ 25� FROM I TO DIAMETER I TMCICMS 51ATERUL
List all applicable welt construction permits(i.e.UIC,County,State,Variance,etc.) ft. N. in.
3.Well Use(check well use): R` R• in.
14 SCREEN.;:.. ...
Water'Supply Well: FROM To DIAMETER I SLOTSIU THICKNESS I MATERIAL
Agricultural C)MtmicipaMbiic ft. ft. I im
Geothermal(Heating/Ciioling Supply) BResidential Water Supply(single) n. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) . .
liri lion FR01r TO MATERIAL E MPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 84 ft. 20 ft* EZ Beal Pump 19
Monitoring Recovery 20 ft. 0 fL Holeplug Gravity 62
Injection Welh'
it. ft.
Aquifer Recharge Groundwater Remediation
=19 SANDIGRAVELEA6K a. Gcable ,
Aquifer Storage and Recovery .Salinity Barrier FROM TO MATERIAL EMPLACEMENT METROD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. %
Geothermal(Closed Loop) E)Tmcer 20 DRILLINGLOG-atti cbadditionelsiieets`ifnetessa s
FROM TO DESCRn'TION color,hardnes soiVrocli 'n sae.etc.
Geothermal(Heating/Cooling Return) Other(ex ]air under#21 Remarks) FROM
0 ft. 25 ft- clay"
4.Date Well(s)Completed:12/08/22 Well ID#20222524 25 fL 45 ft. sandy Overburden
5a.Well Location: ffi fL 60 ft. Quartz vein
Robin& Kevin Amos 60 ft. 74 ft, sandy overburden
Facility/Owner Name' Facility ID#(ifapplicable) 74 tt. 09 ft. solid rock
316 Bridgewater Lane, Mooresville 28117 gp ft- 92 ft- soft vein
Physical Address,City,and Zip 180 ft- 245 ft- connecting vein to neighbor
Iredell 4646 64 2746
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 33 44.266 N 80 51 43.528
tz(8IZ`
6.ls(are)the well(s)ffiPermanent or OTemporary Signature of Certified Well Contractor Date.
By signing this form,I hereby ceHW that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONO with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional 11 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: 245 (ft.) 24a. For All Wells: Submit'this form within 30 days of completion of well
For multiple wells list all depths#'dierent(example-3@200'and 2@100) Construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter:6 00 24b.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:
(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) 10 Method of test:Airlift 24c.For Water Sun&&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 12 oz
13b.Disinfection type: Amount. completion of well construction'to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016