GW1--03319_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams
I4WATER2ONFM:
Well Contractor Name FROM TO DESCRIPTION7
1100 IL 225 fL 9 GPM
4449-A
fL ft.
NC Well Contractor Certification Number
1A OUTER CASING�6 irm]16 r cased M S; LANER(If9016bllel
Rowan Well Drilling FROM I TO DL&METER I THICKNESS MATERIAL
Company Name 0 ft. 1 34 ft- 61/4 -In' 1�.185 I Galvanized
'16X*M WCASMIUMNG:011 G Nebiherinal c1&ed46op).:.
2.Well Construction Permit#: 364968 FROM TO DIAMETER THICKNESS I ALATERLAL
List all applicable well conytruclionpermits(i.e.UIC,County,State,Variance,eta) ft. ft. in. I
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ?,47;SCREEM.,
FROM TO r DMIErER I sLoTsilzE_T_TiflcKNm I MATERIAL
Agricultural J]MunicipaltPublic ft. k in
:lGeothermal(Heating(Cooling Supply) (Residential Water Supply(single) I 1 -1 1
:)
ft. ft. In.
—lIndustrial/Commercial 13Residential Water Supply(shared)
18.GROUT
11rrigation FROM TO MATERIAL FAUPIACEMENr METHOD AMOUNT
Non-Water Supply Well: 0 ft- 20 ft Holeplug Gravity 36
7IMonitoring [31tewvery ft. ft.
Injection Well: ft. fL
:3Aquifer Recharge OGroundwater Remediation
19.:SANDIGRAVEL PACK"da`Rceble
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
DAquifer Test [)Stormwater Drainage % ft.
3Experimental Technology OSubsidence Control ft. &
:)Geothenral(Closed Loop) 13Tracer ­20.-DRILLING LOG6 additibilial ikits1fiui
nGeothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,h soil/rock tym grain s etc.)
0 ft. 16 ft Clay
4.Date Well(s)Completed:4/18/23 Well EN 364968 16 ft 24 ft Weathered Rodd Sand
5a.Well Location: 24 ft, 34 % Solid Rock
Tyler Slagle 48 ft 55 fL Brown Rock
Facility/Owner Name Facility 1139(if applicable) ft. ft.
'k-f
ft. fll. k_0 L7 ki 399 Needmore Rd, Woodleaf
Physical Address,City,and Zip fL ft.
Rowan 802039 �21,REMARKS�l*.�.�,:":"...--..,-.:
County Parcel Identification No.(PIN) ink
[AIMPBOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: go",
(ifwell field,one lattlong is sufficient) 2
35481.022 N 80341.01 w 4t­� 4-1 ( 5 /Z3
6.Is(are)the well(s)OPermanent or [3Temporary Signature ofCcrtified Well Contractor Date
By signing this form,I hereby certify that the Well(s)Was(here)constructed in accordance
7.Is this a repair to an existing well: 0Yes orEJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
if this is a repair,fill out launru well construction Infonnalion and explain the nature offile coo ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/Dff 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-I is needed. Indicate TOTAL NUMBER ofiAvlls construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 —00 24s. For Ail Wells: Submit this formt within 30 days of completion of well
r,or multiple wells list all depths ifelifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:8 VL) Division of Water Resources,information.Processing Unit,
IfIvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter* 6 (in.) 24b.For Injection Well In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this fort,n 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
13s.Yield(gpm) 9 Method of test: weir 24c.For Water SuRnly&Injection MAS: 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; 11oz completion of well construction to the county health department of the county
where constructed.
Form Ow-I North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016