_Well Construction - GW1_20230320 (85)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams
p Y4 WATERrZONES.
Well Contractor Name FROM TO I DESCRIPTION{
4449-A 123 ft- 200 tt• 2 GPM
200 fL 300 ft. zcPM
NC Well Contractor Certification Number 45 OUTER CASING`for moth dasedCwells .OR LINER"if a'`6cable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 123 ft. 6114 r°' SDR21 PVC
Company Name
16INNERCASINGOR=TUBING eo`thermalclosed-too"` "•" "'
2.Well Construction Permit#:WELL-11-2021-160774 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in
Water Supply Well: 47:SCREEN 4�-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERAL
_ Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) g• ft, in.
Industrial/Commercial Residential Water Supply(shared)
lrri ation FROM I TO r ~MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK ifs"livable
_ Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20rDRILLING'LOG attacli additional sheets if neces"sa 4=F „
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soittrock type,grain size,etc.
0 ft. 15 ft, Clay
4.Date Well(s)Completed:2/23/23 Well ID#112021160774 15 ft. 113 ft- Sandy Overburden
5a.Well Location: 113 ft. 123 ft Solid Rock
Cornerstone 3 Properties 140 ft 160 ft- brawn gip
Facility/Owner Name Facility ID#(if applicable) ft. ft
1367 Ron Whicker Dr, Catawba ft. ft. 2023
Physical Address,City,and Zip ft. ft. t t
Catawba 470002966377 21.REtYIARKS° Paz �'�
e J,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 22.Certification:
35 40 27.675 N 80 59 15.284 W Z(23 �23
6.Is(are)the well(s)�X Permanent or Temporary Signature of 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 iX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Iflhis 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 under#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 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: 305 (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@100) 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 27699-1636
13a.Yield(gpm) 4 Method of test: weir 24c.For Water SunDly&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: 1a 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