GW1-2023-02601_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14..WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 112 ft. 240 ft' 2 GPM
240 ft• 400 ft 4 GPa
NC Well Contractor Certification Number
35'.OUTERCASiNG:for multi cased wells OR'LWER ifn"licohle
Rowan Well Drilling FROMTO DIAAKETtS7K TRICININESs MATERUL
Company Name 0 ft. 1 112 ft 61/4 m. SDR21 PVC
311983 16.INNER CASING OR TUBING &tbeimalclosed lo'o
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC.,Cou ly,State, Parlance,etc.) ft. ft. to.
3.Well Use(check well use): ft. & in.
17 SCREEN.';
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TRICKINESS MATERKAL
Agricultural [3Municipal/Pubtic ft. fL in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) p, ft. in.
Industrial/Commercial EIResidential Water Supply(shared)
::18.,GROUT ,
-Irrigation FROM TO MATERIAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' Holeplug Graft 10 bags
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL'PACK ifa li6ble ..;,
Aquifer Storage and Recovery [3Salinity.Banier FROM TO MATERIAL EMPLAMtE1171'METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attmc6[additiooal'slieets ifneces§a
FROM TO DESCRIPTION color hardness.soWrock n size etc
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) 0 fL 20 ft. Clay
4.Date Well(s)Completed:3/24/23 Well W#311983 20 ft. 70 ft. Sandy overburden
5a.Well Location: ro ft. 102 ft- Weathered Rock
Comerstone III Properties 102 ft. 112 ft. sera Rock
Facility/Owner Name Facility ID#(ifapplicable) ft R'
150 Lippard Springs Circle, Statesville 28677 fL ft.
Physical Address,City,and Zip ft. ft.
Iredell 4722663857 1LREMARKS.':
County Parcel Identification No.(PIN)
5b..Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ertif'iCetion:
35 43 55.706 N 80 55 58.931 W
� �24 IZ3
6.Is(are)the well(s)Ox Permanent or 13Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that fire well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or X)No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back ofthis 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 OW-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 (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 a) 00'amd 2@1001 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.) 241b.For infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(Le.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(gpm) 6 Method of test: weir 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
13b.Disinfection type: Chlorine Amount: 19 oz completion of well construction 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
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