GW1-2023-01560_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use On(y:
1.Well Contractor Information:
Spencer Adams 14 WATERZONFs
Well Contractor Name f '�N S�, *-�fD
FROM TO DESCRIPTION
d•
4449-A --`,s `:' �� inn, z45 ft. 305 ft. sn i
'1 q n. ft.
NC Well Contractor Certification Number FEB_p C� t) 2ppli L 3 •15;'QU3'ER CASING'for multi-cased welbbl INEW
Rowan Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
In.n:a�ali^1 PMCZI*,imQ 111Z 0 ft. 61 ft. 61/4f rn• SDR21 PVC
Company Name DWCQ i30G
311995 16INNER.GASING'OR:TUBING' eottierdiat2losed�oo '
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well consinwiton permits(1.e.WC.County,State,Variance,etc.) ft. ft. ! in.
3.Well Use(check well use): ft ft j in.
t19SCREEN'
Water Supply Well: :..:=._; ``._ >:. ":<i
FROM TO DIAMETER IZ SLOT SE MCKNESS IA MATERL
_ Agricultural OMunicipal/Public
Geothermal(Heating/Cooling Supply) xIResidential Water Supply(single) ft, % tn.
Industrial/Commercial E31tesidential Water Supply(shared)
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Holepiug Gravity
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge. Groundwater Remediation
>:19CSANDIGRAVELTACK ifa i licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT MEW011
Aquifer Test 13Stormwater Drainage ft. it.
Experimental Technology 13Subsidence Control &
Geothermal(Closed Loop) OTracer ;2IX DRIBL LOG.iitkic6.addltiiirietstieets itnecessa' : >;: <>5i:r:::
Geothermal(Heatin Coolie Retum Other(explain under#21 Remarks FROM TO DESCRIPTION colon hardness,softeck e n size,eta
0 ft. 20 ft- Clay I '
4.Date Well 1/4/23 311995 s)Completed: Well ID# 20 it. 24 ft. quartz vein
5a.Well Location: 24 ft- 40 ft. Sandy overburden
Comerstone 111 Properties 40 ft. 51 ft. Weathered Rock
Facility/Owner Name Facility ID#(if applicable) 61 f• c, ft. Sorid Rock
148 Lippard Springs Circle, Statesville 28671 ft. ft.
Physical Address,City,and Zip ft. ft.
Iredell 4722 661997 ,2L.REN1ARn`,
i
County Parcel Identification No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laViong is sufficient) 22. ertifieadon:
35 43 53.943 N 80 55 56.866
6.Is(are)the well(s)Ox Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerlfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EINo with 15A NCRC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out/known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 921 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 iveli
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 therein(example-3Q200'and 2®100) Construction to the following:
10.Static water level below top of casing: (ft:) Division of Water R(sources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In?ddition 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 Win) 5 Method of test:welr 24c.For Water Supply&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 , 12oz completion county department county
136.Disinfection type: Amount. p etion of well construction to the coon health d attment of the
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Reso Irces Revised 2-22-2016