GW1-2023-00472_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: �?
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Spencer Adams 14,WATERZONn' >: _. .. J.t FROM TO DESCRIPTION
Well Contractor Name 200 ft 240 ft. a 1
4449 A ft ft
NC Well Contractor Certification.Number Sc^"[ "s= $ 35:UUT6R'GASING formnlH casul.wells'URLTNSR da` liable . s..
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 78 ft- 1 61/4 in- SDP21 PVC
Company Name " ,
3119.94 16%INNERCASING:UR TUBING` eothecmal cldsed-lito
2.Well Construction Permit#s �. ,.i^n ', �'7 llrtri FROM TO DIAMETER THICKNESS MATERIAL
List.all applicable well construction permits C.e.WC,County,State�Yan�i ft• ft. in
3.Well Use(check well use): ft ft. in.
Water Supply Well: . FROM I TO DIAMETER SLOT SIZE THICIINESS MATERIAL�'
Agricultural ®Municipal/Pub'He ft ft. in.
Geothermal(Heating/Caoling Supply) x)Residential Water Supply(single) B, g, in,
Industriai/Commercial 13Residential Water Supply(shared) T8 GROUT
Irrigation FROM TO MATERIAL EMPLACENIENTMETHOD&AMOUNT
Non-Water Supply Well: 0 R• 20 B• Holeplug Gravity 13 bags
Monitoring Recovery ft. ft.
Injection Well:' ft g,
Aquifer Recharge OGroundwater Remediation
19SANDJGRAYELRACIi; ifg.brable:�;�
Aquifer Storage and Recovery Salinity Barrier FROM 110 MATERIAL EMPLACEMENT METHOD
Aquifer Test J3StormwaterDrainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft. i
Geothermal(Closed Loop) ElTracer r20 DltffiU G-LOG:attacfiuddition'af'sbieiarfn y
Geothermal(Heatiu Coolie Retum FROM TO DESCRIPTION color,hardness WVmck in Aw.etc-)Other(explain under#21 Remarks) 0 ft 20- fG day
12/20/22 311994 ft. fr.
4.Date Well(s)Completed: Well ID# 20 30 sandyoverburden
5a.Well Location: ft ft. weathered rode
Cornerstone 3 Properties 68 ft. 78 ft. solid rode
Facility/Owner Name Facility ID#(ifspplieable) & ft.
126 Lippard Springs Circle, Statesville 28677 ft. ft.
Physical Address,City,and Zip ft. ft
Iredeli 4722579136 2VREM ARKS,
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long.is sufficient) 22.Certification:
35 43 58.172 N 80 56 3.376 W i2 2 a
6.Is(are)the well(s)ox Permanent or Temporary Signature of Certified Well Contractor Date
By-signing this form,I hereby cei1ify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:. oYes or !t No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a rgpair,fell out known spell construction information and erplainihe nature ofthe copy ofthisrecord has been provided to the well owner.
repair under 921 remarks section or on the back ofthisform.
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-I 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: 245 fft•) 249. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths ifdij'erent(example-3@200'and 2@1005 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (fn.) 24b.For Infection Wells: I'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.Well construction method: rotary construction to the following:
(i.e.auger,rotary,cable,duect.push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) $ Method of test:weir 24c.For Water Sungly&Inketion Wells: In addition to sending the form to
the. address(es) above, also submit one copy of this form within 30 days of
Chlorine completion of well construction to'the county health department of the county
13b.Disinfection type: Amount: P tY P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016