GW1-2023-02561_Well Construction - GW1_20230410

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Spencer Adams 14.VATERZONES
Well Contractor Name FROM TO DESCMMON
4449-A 3W fl• ass it. 25GPM
ft. ir.
NC Well Contractor Certification Number
15:OUTER'GASING. r.ni6l&6sed:vsells OR=LINER tfu luable
Rowan Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
Company Name ff. 84 ft. g 1/4 in 3DR21 PVC
WELL �9 2�22 $0387 . MANNER CASING.OR-TUBING eothernial dosed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc..) ft. ft. in.
3.Well Use(check well use): fL tt. in.
Water Supply Well: i?c:SCREEN
FROM TO ..-DIAMETER SLOT SIZETHICKNESS 1SrATERIAL
Agricultural E]Municipal/Public L�E
it. in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single)
ft. in.
IndustrialtCommercial Residential Water Supply(shared)
18.GROUT:::
Irrigation FROM TO MATERIAL E11IPI.ACEMENT hiETROD&AAfOUNT
Non-Water Supply Well: 0 it 20 ft. HOLEPLUG GRAVITY 7
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge ft. ft.
Groundwater Remediation
19:SAND/GRAVEL PACK ifa"licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL ESfPLACENI[ENT 11lETHOD
Aquifer Test nStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG:attackadditional'sheet'sifnecessetry
Geothermal(Heating/C oling Return) rJOther(explain under#21 Remarks) FROM TO L
DESCRIPTION color,hardness,soiUrock type.Itruin size,etc.
0 It. 20 It. CLAY
4.Date Weil(s)Completed:3/21123 Well ID#092022180387 20 ft. 45 ft.
SANDY OVERBURDEN
5a.Well Location: w IL 74 ft. WEATHERED ROCK
KAREN MCRORIE 74 ft. --;;—ft. SOLIDROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2491 SETT'LEMEYER BRIDGE RD, NEWTON 28658 ft. rt.
.Physical Address,City,and Zip ft. ft.
CATAWBA 372007580757 2L REMARKs' APR I
County Parcel Identification No.(PIN) a,• .- .nn i!_S.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 40 36,457 N 81 16 19.977 W
_1444� .5 (Z t 23
6.Is(are)the well(s)0Permanent or OTemporary —Signatu&of Certified Well Contractor Date
By signing this forth;I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or []No with 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
If this is a repair,fill out known well construction information and explain the mature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or or the hack 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: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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"i-" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
ROTARY above,also submit one copy of this form within 30 days of completion of well
(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 276994636
13a.Yield(gpm) 25 Method of test: WEIR 24c.For Water Supply&Infection Wells: In addition to sending the form to
CHLORINE 17 Oz the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction tot the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resour s Revised 2 22-2016