GW1--03867_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-I) For Internal Use only:
1.Well Contractor Information:
Spencer Adams
14.WATER ZONES..w
Well Contractor Name FRO51 TO
4449A 110 ft 180 ft. 20M
NC Well Contractor Certification Number 200 ft. 280 &
Rowan Well Drilling AS-OUTERCASING�f0iiy2ulti4aied-*e Us''OR IAINER if lic-able
FROM To DLOMM TMCKNESS MATERIAL
Company Name 0 fl. 110 110 61/4 in. SD" PVC
310706 X INNER CASING OR TUBING. eothermnl closed4 ,0
2.Well Construction Permit#: FROM TO DMIETER TMCMK N
List all applicable well construction penmis#.e.WC,C49wqv,T,.,7 Tarianc,.—,tc.) & ft. iESS ilAURIAL
3.WeR Use(Check well use): ft.
Water Supply TV—ell-
FRO%[
I DLAMETER SLOTSIZE
Agricultural 0MUniciPaL/Public ft ft in.
Geothermal(Heating/Cooling Supply) 011esidential Water Supply(single) ft. ft In.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation
No Supply Well: MIPLACEAlEm r�w mun AMOUNT
0 ft 20 It holeplug graft 60
:iMonitoring ORecovery & ft.
Injection Well: -
3A1uifer Recharge oGroundwater Remediation ft. ft.
3Aquifer Storage and Recovery DSalinilyBanrier 19,SAND/GRAVEL,L PACK
AfATERLiL
Aquifer Test J3 Stormwater Drainage FROM ft TO ft. ENIMACENIENTMEMOD
Experimental Technology oSubsidence Control ft. ft
Geothermal(Closed Loop) C)Tracer
u20.-DRILLING had
eo ROM To
I Geothermal(Heating(Cooling Return) Other(explain under B21 Remarks) F DESCRIMON color,h ' soiUrork size eta
4.Date Well(s)Completed.5/2/23 Well ID#310706 0 ft-ft is ft clay
75 50 ftsandy overburden
5a.Well Location: tt 100 ft.
V LJ
pinkgravel
too ft
Cornerstone III Properties —110 fL soUdrock
Facility/Owner Name
Facility ID#(ifapplirable) ft. ft. U ;,v
123 Pleasant Creek Dr, Cleveland ft.
rt
ft.
Physical Address,City,and Zip 2l. ft
Iredell 4760 58 4737 REMAR KS
County Parcel Identification No.(PN
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(ifwell field,.one Wong is sufficient) 22.Certification:
35412.526 N 80 48 0.547
JIL� 5 j 2- 13
6.Is(are)the well(s)OPernument or OTemporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the nell(s)ivas-(mere)constructed in accordance
7.Is this a repair to an esisting well: []Yes orElNo with 15A NC4C 02C.0100 or 15A NC4C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known melt construction information and explain the nature ofille copy ofibLs record has been provided to the hell owner.
repair under 01 remarAN section or on the back ofthis form. 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1
SUBMITTAL INSTRUCTIONS9.Total well depth be.low land surface: 285
example-3@200'and2@100)
For multiple wells list all depths i(different( It-) 24a. For At Wells: Submit this form within 30 days of completion of well
30 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level Is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 L Borehole diameter. 6 —00 24b.For Iniection 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:
FOR WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 10 Method oftest-weir 24e.For Water Supply&Inmectirm Wells: In addition to sending the form to
13b.Disinfection type. chlorine 13 oz the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016