GW1--03866_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FRO51 TO I DFSCRD'YION
4449-A ss fc zgo ft. I I
110 cox
NC Well Contractor Certification Number fr. &
'1S:OUTER"CASING foi n dii caselwelh`oRI INER'ife'"kcable
Rowan Well Drilling FROM TO DIAMETER TAIClt111ESS KIATERUL
Company Name 0 f6 66 ft. 61/4 in. SDR21 pVC
2022-10857 ]GINNER CA SINGORTIJBiNG eotliermaletosedloo
2.Well Construction Permit#: FROM TO DtMf6IER THICIQVRRSS '111ATERiAL
List all applicable ivell construction permits(i.e.UIC.County,State,Yartance,e1c.) ft ft in
3.Well Use(check well use): R ft. in.
Water Supply Well: 19.SCREEN
cultural FROM TO DIAMETER ISLOTSIM TMCKNFSS 'hrATERNL: ,..�Municipal/Public fi � in,
ermal(Heating/Cooling Supply) iResidential Water Supply(single)
ft. ft. In.
triaUConnnercial E3Residential Water Supply(shared)
is:cROVT _.
015E,
tion FROM TO MATERIAL EArpLACF11rElY[MEIHOD&AhrOUNT
Non-Water Supply Well. 0 fL 20 ft. HoleWu9 Gravity 18 bags
Monitoring DRecovty fr
Injection Well:
Aquifer a ft
9 g OGroundwater Remediation
Aquifer Storage and Recovery Salmi Barrier 19:SAND/GRAVEIL:PAQt Ufa Ticsble':_ 777.7
- FROM - TO tiL1TERIAL HMPLACEMENTtvJMJOD-
Aquifer Test []Stormwater Drainage ft ft.
Experimental Technology OSubsidence Control tr ft
Geothermal(Closed Loop) MTmcer
-'2E DRILEN LOG"raffrch:additloneiet eeb itnecas
Geothermal(HeatingIC00HP&Return) Other(explain under#21 Remarks FROM To DESCRi WO—N color harda solVrock rain sae etc
0 ft. 1a Clay
4.Date Well(s)Completed:5/12/23 Well ID#2022-10857 18 ft' 30 to
sandy overburden �..,
5a.Well Location: so & 56 fr weaftred rack
Sherman Phifer Ss ft. solid rock
Facilitylowner Name Facility IDll(ifopplicable) 70 ft r4 ft tanrock J
426 Pilch Rd,Troutman 4RELtAR
fi: tfllorw:railett Farn, ,��I
Physical Address,City,and Zip ft. '�9.14i1
Iredell 4751 14 9207 z1IGS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one h0ongis sufficient) =7�
354154.340 N805044.733 W ,{ /I
6.Is(are)the well(s)Ox Permanent or OTemporary Signature ofCertified well Contractor Date
By signing this form,I hereby certify that the uell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 9NO with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
ifdnir is a repair,fill out known ivell construction information and explain the nature ofthe copy ofthis record has been provided to the irell owner.
repair under P21 remarks section or on tine back ofth/sform.
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 ofwells construction details. You may also attach additional pages ifnocessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdffereut(example-3@a 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifrsater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 -) 24b.For Injection 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
(Le.auger,rotary,cable,direct pusb,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 hlat7 Service Center,Raleigh,NC 276994636
13s.Yield(gpm) 1.5 Method of test: Airlift 24c.For Water Supply&Injection 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: 1702 completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016