GW1-2023-02558_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal.Use Only:
I.Well Contractor Information:
Spencer Adams 14.WATER ZONES d`
FROM TO DESCRIPTION
Well Contractor Name 123 ft 300 fl. 1 GPM
4449-A 300 ft. 425 ft* 2 GPM
NC Well Contractor Certification Number 15.013TER CASING for•multi=casedwells..OR'LINER.tf u'ticnble'
Rowan Well Drilling FROM TO DIAMETER; THICKNESS MATERIAL
0 ft. 123 ft* 61/4 1D' SDR21 PVC
Company Name 16:INNER CASING OR TUBING' eiothermaI'dosed400
WELL 10 2021 158800
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL ft ft. in.
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.)
ft. It.
1n
3.Well Use(check well use):
17?SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS J%fATERIAL
Agricultural [3MunicipaYPublic 8. it• 1°
Geothermal(Heating(Cooling Supply) EIResidential Water Supply(single) ft ft.
Industrial/Commercial Residential Water Supply t (shared)
18;GROUT
Ini ation FROM I TO MATERIAL ENtPLACF.MENTMETHOD&AifOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holepiug Gravity 13bags
Monitoring Recovery ft. tt.
Injection Well:
Aquifer Recharge [3Groundwater Remediation 19.SAND/GRAVEL PACK if Optical)le
Aquifer Storage and Recovery .Salinity Barrier FROM TO MATERIAL EtiiPLACE91F1VT 11tETHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20DR1LLING LOG'sttadi eddiNanot sheets if uecesse
F ;;;
ROM TO DESCRIPTION rotor hardness,sokUrock in size,etc
Geothermal(Heating/pooling Return) Other(explain under#21 Remarks) 0 ft. 22 ft. clay
4.Date Well(s)Completed:
3/8/23 Well ii>#102021158800 22 ft. 100 tt• sandy overburden
too ft 113 ft. weathered rock
59.Well Location:
Cornerstone III Properties 1,3 ft 123 ft• soridrock
Facility/Owner Name
Facility ID#(if applicable) 131 ft- 137 ft. brown rock veinFr- 3
1405 Karriker Lane, Catawba 148 f" 156 ft• brown rock vein 3
ft. ft. i
Physical Address,City,and Zip
Catawba 470002876253 21:1tEnIARKs ; lni, pr-Ni� ' ';`
Vi}vim Ji�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) zzWell
354037.351 N805926.661 W Contractor Date
6.Is(are)the well(s)ox Permanent or Temporary
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 EJNo with I5A NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of ilia copy of this record has been provided to die well owner.
repair wider f21 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: 425 (ft.) 24a. jaor All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(-ample-3@200'and 2@100) construction to the following:
ft. Division of Water Resources,Information Processing Unit,
f Static water level below top of casing: ( ) 1617 Mail Service Center,Raleigh,NC 27699-1617
Ijwater level is above casing,use"+"
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 Alail Service Center,Raleigh,NC 27699-1636
Method of test:Weir 24c.For Water Supol &Infection We1b; In addition to sending the form to
13a.Yield(gpm) 3 - the address(es) above, also submit one copy of this form within 30 days of
Chlorine Amount- 20 oz completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016