GW1-2023-01399_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams -.'14.1.,WATER-z0NU:,
Well Contractor Name U FROM I TO DESCREMON
122 ft. 180 ft. acme
4449-A
NC Well Contractor Certification Number FEB 0 8 2023 930 ft- ft
A 5.'0 Uf-E K R Lffffilo q W d; a d
Rowan Well Drilling To Unit FROM I TO DIAMETER TEUCKNESS MATERIAL
Company Name 0 ft. 22 1 1 ft' 6 114 In' SDR21 PVC
INC.fteofhe6id diiWAOJ;� —
W22 l67'MFR'rASWG
2.Well Construction Permit#: 24 FROM ' i TO DL41VZUR I THICENESS I MATERIAL
Lim all applicable well construction permits(Le.UIC,County,Stare,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft. ft. in-
-173CREEN,:�'
Water Supply Weil:. FROM TO I DIAMETER'
I SLOT SUE THICKNESS
Agricultural ON[unicipalftblic & & it
AIATERML
Geothermal(Heating/Cooling Supply) [3Residential Water Supply(single)
Industrial/Commercial 13Residential Water Supply(shared)
-;I&-',GRO UT
irrigation FROM I TO MATMAL EMPIACENIENTNEMOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Hole'pfug Gmvily 14
:)Monitoring [3Recovery ft, IL
Injection Well: - P
Aquifer Recharge OGroundwaterRemediation ft. ft.
-d
."19,*,SAND/GRAV,EL-PA
V
Aquifer Storage and Recovery (3Salinity Barrier FROM TO MATERIAL EMPLACEMENTMET1101)
Aquifer Test E)Stomwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer
320�DRIU-INGLDG-(iifttltidditiofi'at�heetslf
- Geothermal(Heating(Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color bards ms ktypegralusizeetc.) I
0 ft- 15 ft. clay
4.Date Well(s)Completed: 1131/23 Well ID#W 22 24 15 ft. too ft, S.4'Overburden
Sa.Well Location: 1W & 112 ft- Weathered Rock
Lovelea Farms M 122 Solid Rock
Facility/Owner Name Facility ID#(if applicable)
Linwood Southmont Rd, Lexington ft ft.
Physical Address,City,and Zip & ft.
Davidson 0601400000006 .1l.REMARKS-,----
County Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lafflong is sufficient) 22
35 43 56,0300 N 801855.505
6.Is(are)the well(s)OPermartent or OTemporary Signaturl of Certified Well Contract6r Date
By signing this form.I hereby certo that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well; DYea or Mx No with 15A NCAC 02C.0100 or IJA KCAC 02C.0200 Well Construction Standards and that a
1(this is a repairfdt out blown well construction it formation and eWlaln the nature ofthe copy ofthis record has been provide,I dto the well owner.
repair under#21 remarks section or on the back ofthisfom. 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: 946 11
For multiple wells list all depths�rdtjereni(erample-3@200'and 2@100) 24s. For All Wells Submit this farm within 30 days of completion of well
construction to the following: i
10.Static water level below top of easing: 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 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:
(Le.auger,rotary;cable,direct push,etc.) I '
Division of Water Resources,Uuderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Servie e Center,Raleigh,NC 27699-1636
70+ weirWater
I I
13a.Yield.(gpm) Method of test: 24r—For Wa r sonall&IU4 don Wells: In addition to sending the form to
265 lbs Chlorine Amount: the address(es) above, also so mit one copy of this form within 30 days of
13b.Disinfection type: completion of.veil construction to the county health department of.the county
where constructed,
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resou I rees Revised 2-22-2016