_Well Construction - GW1_20230320 (30)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 'T
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 48 it, 220 it. 15 GM
220 O• 280 it' 13 GPM
NC Well Contractor Certification Number 45.MITER:CASING for:mdti c.med,welb OR:LIN faolficgble
Rowan Well Drilling FROM I TO I DIAMETER I THICKNESS MATERIAL
Company Name
0 it 48 it- 1 6114 in' I SDR21 PVC
•
2022-00003260 16 INNER CASING:OR;TtIBING eotbermat closed too
2.Well Construction Permit#: FROAi TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i e.WC,County,State,Variance,etc.) ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;SCRCEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural E)MunicipaUPubiic ft. ft. in
Geothermal(Heating/Cooling Supply) X)Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) ..
1&::GROUT:
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Wafer Supply Well: o ft, 20 ft. Holeplug Gravity 11 bags
Monitoring CIRecovery ft. ft.
Injection Well: tt. ft.
[Experimental
fer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if a ligble
fec Sfor a and Recove Salim Barrier
a$ rY tl FROM TO MATERIAL EMPLACEII>ENTMETHOD
fer Test 13Stormwater Drainage it. fr.Technology Subsidence Controlhermal(Closed Loop) Tracer 20 tDR1LLINGt1 OG atltiith'addtlionetsbePis 1f aechermal eatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soilfrock 'n size,etc.
p ft. 18 ft. Clap/S�ele
4.Date Weil(s)Completed:2/16123 Well ID#202200003260 18 ft. 48 ft. Solid Rock
5a.Well Location: ft. 74 ft. Brown vein
Jim Johnson ft. fr. e _
Facility/Owner Name Facility.ID#(if applicable) ft. ft. 5 '� •:- ?r' q „ 5
6876 New Hope Rd, Denton it. it. MAR 2 0 707.
Physical Address,City,and Zip ft. ft.
Randolph 6696718136 2L MUM'
County Parcel Identification No.(PIN).
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35 33 41.790 N 80051.142 W
L(j (Q (z3
6.Is(are)the well(s)oPermanent or OTemporary 'Signature 6f Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or )No with 1SA NCAC 01C.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 nottire of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of thisfom.
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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Tar multiple wells list all depths if different(example-3@200'and 2@I005 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 (in.) 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 276994636
13a.Yield(gpm) 3 Method of test: weir 24c.For Water SunDly&Infection 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: 19 O2 completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016