GW1-2023-00473_Well Construction - GW1_20230109

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams i4:WATERZONES' :,,Well Contractor Name FRObI TO DESCRIPTION
78 ft 400 ft
4449-A ft n
NC Well Contractor Certification Number ,t_
�13 1S:OUTER CASING,f07ii iti�cased'::ivells.OR LINER`if ii "heable `._
Rowan Well Drilling FROM I To DIAMETER THICKNESS 5UTERL41
I n�l tl it "i f19 2 o ft: 78 ft. 's va 1°• soR21 PVC
Company Name
311�96- '>I6:INNER<CASINGORTUBING euthermal closed loo . ...
2.Well Construction Permit#• '�'~n Pm--"w'";'j u ''i FROM To DrAn>ETER THICKNESS I MATERIAL
List all applicable well construction permits(I.e.UIC,Count V,°Sth W Fd;ionce,etc.) ft. ft. in-
3.Well Use(check well use): fa ft. in.
Water Supply Well: ;FRO GREEN�,; rt• DWMER I,+SLOT SIZE THICKNESS I MATERIAL'
Agricultural 13MunicipaUPublic & ft. in.
Geothermal(HeatinglCooling Supply) Residential Water Supply(single) & & in
Indusfrid/Commercial Residential Water Supply(shared) =16.GROU f `
hTl anon FROM TO AIATERUIL EMPLACEi•D M METHOD&AMOUNT
Non-Water-Supply Well: 0 % 20 rt• Hweptu9 Gravity 13 bags
Monitoring. - DRecovery ft. ft. '
Injection Well: ft. A.
Aquifer Recharge []Groundwater Remediation
19:SANDIGRcSVFLPACK'ifs. livable ,
Aquifer Storage and Recovery E)Salinity Barrier FROM To I WATERUIL ENIPLACEDIENT METHOD
Aquifer Test OStormwater Drainage ft. rt•
PExperimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) DTracer 20::DRiI IiINGZOG atfacli addibooai sheets ifnecess f
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FRO" TO DESCRIPTION color,hudness,so0/rock sae,etc.)
0 rt- 15 ft• I dey
4.Date Wcll(s)Completed:12/19/22 Well ID#311996 i5 ft. ao ft
sandy overburden
5a.Well Location: m fr. ft weathered rock
Cornerstone III Properties se ft. 78 n• solid rock
Facility/Owner Name Facility ID#(if applicable) 84 ft. „a ft soft brown rock
120 Lippard Springs Circle, Statesville 28677 rt it.
Physical Address,City,and Zip ft. ft.
Iredell 4722578232 `:21REafARKS
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.C titivation:
35 43 58.718 N 80 56 5.001
(2 � I,�! 1Z2--
6.Is(are)the well(s)ox Permanent or Temporary Signature ofCer;ified Well Contractor Date
By signing this form,I hereby!certify Hurt the well(s)was(were)constructed in accordance
T.Is this a repair to an existing well: 13Yes or JMNo with 15ANCAC 02C.0100 or 15R 11'CAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out lwown well construction information and explain rile nature of the copy ofthis retard has been provided to the well owner_
repair wider#21 remarks section or on the back ofthis form.
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: 425 (it•) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all deptlxs ifdifferent(example-3@200'and 2@100) construction to the following:
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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 (in.) 24b.For Iniection Wells:. 1 In addition to sending the form to the address in 24a
ry above, also submit one copy]of this form within 30 days of completion of well
11 Well construction method: Rota construction to the following-
(i.e.auger,rotary,cable,direct push,etc.) i.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
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13a.Yield(gpm) 1'5 Method of test:weir 24c.For Water Suppiv&Iniection Wells: In addition to sending the form to
the address(es) above, also 'submit one copy of this form within 30 days of
chlorine 20oz completion of well construction to the coup health department of the coup
13b.Disinfection type: Amount: P county P county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016
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