_Well Construction - GW1_20230320 (78)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •.„
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 280 ft. 325 ft. 20 GPM,
4449-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multiriased wells OR LINER if a licable .
Rowan Well Drilling FROI TO DIAi1mETER THICKNESS MATERML
0 ft. 44 ft. 1 6114 in. I SDR21 PVC
Company Name '
2022000042 16.INNER:CASiNG OR TUBING eother at closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS bL►TERIAL
List all applicable well construction permits(e.VIC,County,State,Variance.etc) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in
__ Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) g, ft. in
Industriakornmercial E)Residential Water Supply(shared) 18.GROUT
-Irrigation FROM TO 1ATERML EMPLACEMEAT MEIROD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Holeplug Gravity 10
Monitoring Recovery ft. ft.
Injection Well:. ft. ft.
_ Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL:PACK if a livable
Aquifer Storage and Recovery OSalinity Barrier FROM I To I MATERIAL I EMPLACEIIiENT titETHOD
Aquifer Test E)Stotmwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hnrdoess.soilfrock type,gmin size,etc.
0 ft. 18 ft, Clay,
4.Date Well(s)Completed:2/6/23 Well ID#2022000042 18 ft. 30 ft- Weathered Rock
Sa.Well Location: 30 ft. 44 fle Solid Rode
Gary Wood 52 ft. 55 ft, Brown vein
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1301 Rocky Cove Lane, Denton ft. ft.
Physical Address,City,and Zip ft. ft.
Davidson 21.RE F7 i
County Parcel Identification No.(PIN) e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if is sufficient lnior.•f-a.'I'D-n P1r^:�2;r Dr;?1
( g ) 22.C rtification:
35 37 19.544 N 80 12 11.826 W p
"Z 13
6.Is(are)the well(s)OPermanent or OTemporary Signature of tcrtified 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: []Yes or XX No with 15A NCAC 01C.0100 or ISA NCAC 01C.0200 l tell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair wider#21 remarks section or on the back of this 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 I 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: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 10 (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%Neils: 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) 20 Method of test:Air lift 24c.For Water Supply&injection 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: 15 oz 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 Resources Revised 2-22-2016