GW1-2023-02363_Well Construction - GW1_20230320

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
98 ft. 300 ft. is cam
4449-A
NC Well Contractor Certification Number i?15 OUTElt'CASING for multi-cased wells)OR'L1NER;if ti htsible
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 98 ft. ;6114 tn• SDR21 PVC
Company Name ,
ZOZZ-000OZZ9H ':16.INNER CASING OR•TUBING eothermal closed loo ;•.
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt, la
'ATSCRE
Water Supply Well: FROM EN,I TO DIAMETER I SLOT SIZE` THICKNESS MATERIAL~
Agricultural OMunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. ]n
Industrial/Commercial []Residential Water Supply(shared) 18:GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft, Holeplug Gravity
Monitoring- CIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SANDIGRAVEL-PACK if:a '►icable':
r ' Aquifer Storage and Recovery 13Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology ElSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:'DRILLINGLOG:attoeh:additiooel'sheetsiEuecessa
Geothermal(Heating(Cooling Return) Other(explain under#21 Remarks) 1 FROM I TO DESCRIPTION color,hardnM solUrock tyVe.grain sue etc.
0 ft. 20 ft. (Clay
4.Date Well(s)Completed:2114/23 Well IDfI 2022-00002298 20 ft. 60 ft. Sal„dy overburden
5a.Well Location: m ft. 68 ft. Weathered Roar
Holly Hogan E9 ft, 98 ft, Solid Rock
Facility/Owner Name Facility ID#(if applicable) 110 ft• +u ft• Brown Rode
3295 Grange Hall Rd,Asheboro � f-�
Physical Address,City,and Zip ft. ft.
Randolph 7619021098 2r:REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
35 38 50.914 N 79 58 32.217 W
6.Is(are)the well(s)�X Permanent or Temporary Signature ofCCe—rti-fieed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordmrce
7Js this a repair to an existing well: MX Yes or E3No with/SANCAC 02C.0100 or ISA NCAC 02C.0200 iirell Construction Standards and that a
Ifdris is a repair,fill out known well construction information and explain the nature of the copy of this retard 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 I 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: 405 (It.) 24a. For All Wells: Submit this font within 30 days of completion of well
1--or multiple wells list all depths Ifdierent(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 farm to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
(L.Well construction method:
(i.e.auger,rotary,cable;direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1.5 Method of test:Weir 24c.For Water SunDly&Iniection 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: 79oz completion of well constntetion 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