GW1--03240_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Spencer Adams 14.WATER zoNEs
Well Contractor Name F
ROMIPTIOY
4449-A ft
NC Well Contractor Certification Number
i
15:OI7TER'CASING for+mold=caased wells OR LINER if n" liable
Rowan Well Drilling FROM To DIAMETER THICKNESS MATEt21AI
Company Name p ft. &,r ft. 6114 in. SDR21 PVC
well 02 2023 189145 u:INNER CASING.ORTUHING eothei'mitleioscd=Ion
2.Well Construction Permit#: FROM TO DIAMETER Taiczav0 MATERIAL
List all applicable well constWc110n pert nts(i.e.WC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): & ft. in.
Water Supply Well: 17:5GREEN `.': _..
FROM TO DiAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft, ft. in.
Geothermal(Heating/CoOling Supply) xMResidential Water Supply(single)
fr. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
481GRODT
Irri attOR FROM TO M1iATERiAI FIKPLACEIIIENT.hR TROD&AMOUNT
3.Non-Water Supply Well: p ft- 2p ft Holeptug Wavily 8
Monitoring Recovery Injection Well: ft, ft.
:?Aquifer Recharge ft. ft.
q � Groundwater Remediation
19.SAN DIG RAVEL'PAC K if a liciable Aquifer Storage and Recovery Salinity Barrier FROM To
AATERIAL EMPLACEDIENT AIETHOD.
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft. ft,
Geothermal(Closed Loop) �l Tracer
O ;"RiLLINGLOG attach addihonel sbeets if necessa:
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DEseRH'TION eotor,hardoess=i; o size etc.
p & 20 ft. clay j
4/11/23 022023189145 4.Date Wells)Completed: Well ID# 20 ft 55 ft• weathered rock
5a.Well Location: $ ft- 65 ft. Solid Rock
Todd GallowayConstruction
tt. fr. .. IN
...w
Facility/Owner Name Facility lD9(if applicable) ft. ft.
8511 Dog Leg Rd, Sherrills Ford 28673 fr. ft.
Physical Address,City,and Zip fr ft.
4z 1f h r
i Ira
REn1ARKs
Catawba 461902556538 i1
..
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iattlongis sufficient) 22. ertilieation:
35 38 48.075 N 80 58 3
6.Is(are)the well(s)OPermanent or Temporary Signaturd of Certified Well Contractor Date
By signing this form,I hereby certify that the we (s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or JRNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 renzarkv 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: 805 (ft-) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(erample-3@200 and 2@1005 construction,to the following:
10.
f
water level is above casing,use"i Static water level below top of casing:40
If Division of Water Resources,Information Processing Unit,
" (ft.) Division
Mail Service Center,Raleigh,NC 27699-1617
I1.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 27699-1636
13a.Yield(gpm) 2 Method of test:weir 24c.For Water SunDly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: chlorine Amount: z.3otbs 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