GW1-2023-02602_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 I TO DESCRIPTION
4449-A 200 ft. 300 ft, a G
NC Well Contractor Certification Number 300 fry 400 ft. a GPM
15:OUTER CASING)for inirlti;eased4ells.`OR LINER Cif o liwble
Rowan Well Drilling FROAf TO DIAIIIETER THICKNESS MATERiAL
Company Name 0 ft. 94 ft. 61/4 in. SDR21 PVC
2�23_�36$$ 16.INNER CASING OR TUBING eottiermal.closed+too
2.Well Construction Permit#: FROar TO DIAMETER I THICKNESS r11ATERIAL
List all applicable well construction permits(i.e.WC.County,Slate,Variance,etc.) ft,
ft. in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: -:17 SCREEN'::
FROJI TO DIAMETER SLOT SIZE I THICKNFSS MATERIAL
. Agricultural []Municipal/Public tL ft. in.
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft, ft. in.
IndtistriaUCommercial Residential Water Supply(shared) 18.GROUT::
Irri ation FROM To bIATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Z0 ft. Holeplug Gravity
Monitoring DRecovery fit Et.
Injection Well:
ft.
Aquifer Recharge [)Groundwater Remediation ft.
Aquifer Storage and Recovery Salini Barrier 19 SAND/GRAVEL PACK if a licable
t FR091 TO 1%UTERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer "20i DRILL ING'LOG attach additional sheets if heee ' r,;::,-.
Geothermal(Heatin Cool ing Return) Other(explain under#21 Remarks) FRO51 TO DESCRIPTION color,hardness soil/rock type.grain size.etc. '
0 fit. 20 fit. Clay
4.Date Well(s)Completed:3/17/23 Well ID#202313688 20 ft. 40 ft,
Sandy Overburden
5a.Well Location: 4D ft- 84 ft Weathered Rode
Gregory Hills e4 ft- 94 ft, Send Rock _
rz. .
Facility/Owner Name Facility MY(if applicable) 94 ft• 120 fr. Broom hard rode
163 River Ridge Lane, Statesville 28677 fir. fr. PQ
- -
Physical Address,City,and Zip ft. ft.
Iredell 4710583188 21.REn1ARKs'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if%veil field,one latflong is sufficient) 22.Certification:
35 40 49.050 80 58 6.780
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Dale
By signing this fomi,1 hereby certo that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or XIMNo with 15A.NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If ibis is a repair,fill out known well construction hrformation mid explain the nature of dre copy of this record has been provided to the well owner.
repair under 621 remarks section or on the back of dusform.
23.Site diagram or additional well details:
8.For Gcoprobe/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 swells construction details. You may also attach additional pages if necessary,
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (fit•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(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 wvater level is above casing,use"+" 1617 mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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.Weil 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 276994636
13a.Yield(gpm) 10 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: Chloride 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