GW1-2023-02560_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams :14.WATER-Z4DNES t
FROM TO DESCRIPTION
Well Contractor Name
200 ft. gpp ft. 4 GPM
. 4449 A ft. ft.
NC Well Contractor Certification Number 15 OUTEWCASING Wr multi-cased'.weIIS'OR LINER'ffabblicitble
Rowan Well Drilling FROM I TO DIAMETER THICKNESS I MATERIAL
0 ft. 62 ft• 6114 1n• SDR21 PVC
Company Name 16t"LINERCASING`OR:TUBING' eothermal:closeil=loo
2.Well Construction Permit#:WELL 04 2022168758 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
IWSCREEN
Water Supply Well: FROM I TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating(Cooling Supply) [DResidential Water Supply(single) tt tr. in.
Industrial/Commercial 13Residential Water Supply(shared) ;18:GROUT
hTi ation FROAI TO AATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 % HOLEPLUG GRAVITY 16 BAGS
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge oGroundivater Remediation 6:.19 SAND/GRAVEL-PACK f applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fa
Experimental Technology oSubsidence Control
Geothermal(Closed Loop) Tracer 20 DRILUNG'LOG.(attach addiNonel°sheets.i['n
FROM TO DESCRIPTION color,hardness,soittrock g rain sa em
Geothermal(Heating/Cool in Return) Other(explain under#21 Remarks 0 % 20 ft- CLAY
4.Date Well(s)Completed:3/10/23 Well ID#042022168758 20 ft. 40 ft. SANDYIOVERBURDEN
m ft' S2 ft. WEATHERED ROCK
5a.Well Location:
PRINCETON LAND DEVELOPMENT 52 ft- 62 fl- SOLID ROCK r'�
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
8072 CYPRESS ST, SHERRILLS FORD 28673 ft. fr. 1 0 9nn
ft. ft.
Physical Address,City,and Zip .
461703013140 21.-REMARKS' .
CATAWBA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one littlong is sufficient) 22.Certification:
35 34 40.841 N 80 58 59.722 `,i,
� Signabue o Certified Well Contractor Date
6.Is(are)the well(s)� !Permanent or �Temporrry
By signing this form,I hereby certify that the nel!(s)was(were)constnrcled in accordance
7.Is this a repair to an existing well: [3Yes or [MNo with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out know"well construction information and erplain the nature of the copy of this record has been provided to the well owner.
repair under 4,21 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 GW4 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 spells list all depths if different(example-3@200'and 2@100) construction t0 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 Injection 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
Method of test:WEIR 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) 4 the address(es) above, also submit one copy of this form within 30 days of
CHLORINE Amount: 14OZ completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Reso
Revised 2-22-201 G