GW1--03865_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams A&WATERZONES r.
FROM TO DESCRIPTION
Well Contractor Name
125 it• 150 iw s rau
4449-A
ft. ft
NC Well Contractor Certification Number 15 OUTER CASING foemald-cased.Wells ORt NER ite"lieable "'
Rowan Well Drilling FROM TO DIAMETER i I THICRNM MATERIAL
0 ft. 87 ft, 6114 in.'I SOP21 PVC
Company Name n'/� 16.;INNER CASINGi:OR TUBING eotbermal closed-too
2.Well Construction Permit#: ,V„ FROM TO DIAMETER THICKNM MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) fL IL in.
3.Well Use(check well use): ft. ft. in,
47.
Water Supply Well: FROMREI TO I DIMdETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural 0Municipal/Public ft. & to
Geothermal(Heating/Cooling Supply) 011esidential Water Supply(single) fL fL in
Industrial/Commercial Residential Water Supply(shared)
X11nigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: 0 % 20 ft. Holeplug Gravity 10 bags
Monitoring DRecovery ft. ft.
Injection Well: ft. &
Aquifer Recharge OGroundwater Remediation
19 SANiNGRAVELPAGI{ ifa likable is
Aquifer Storage and Recovery 08alinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)StormwaterDramage ft ft:
Experimental Technology [3Subsidence Control ft. iL
Geothermal(Closed Loop) 13Tracer 20"DRiIT7NGIOG attach ad ditionatibeNsifnecese777777
Geothermal (Heating/Cooling Return) n0ther(explain trader#21 Remarks FROM TO I DESCRIPTION color,hardnes,so Wrock n sue.etc
0 ft 22 ft- brick,day,concrete
4.Date Well(s)Completed:4128/23 Well ID#NA 22 ft. 56 ft. sandy overburden
Sa.Well Location: aft. 77 ft' weathered rock G
ft. 87 ft- sold rock
Wayne SeverankrJBeach ConsWklion I !� r
Facility/Owner Name Facility ID#(ifoppfi U cable) it ft N V 9 2023
500 S Main St, Mooresville ir. ft.
Physical Address,City,.and Zip +
Iredell 2t:RE11fARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one[at/long is sufficient) 22. rt�catlon:
35 34 29.560 N 80 49 3.896 W S- 2,J
6.Is(are)the well(s)oPermanent or Temporary igaltura fCettifiedweitContractor Date
By signing this form,I hereby certify that the irell(s)was(vere)constructed in accordance
7.Is this a repair to an existing welk 0Yes or ®No uith 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information ad explain tire nature of the copy ofthis record has been provided to the urll miner.
repair under#21 remark 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 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: 245 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifili ferent(example-3@200'and 2@I00) 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 (ID.) 24b.For Inicetion 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) 5 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: 12 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 i Revised 2-22-2016