GW1--03883_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams AiLVATERZONn.t
FROM I TO I DESCREMON
Well Contractor Name
44 ft 265 ft a cvu
4449-A ft. %
NC Well Contractor Certification Number 1SrpUTER CASING:for multi=etiied vrelis'OR:tifNER "e "Gcabte
Rowan Well Drilling FROM TO DtAM1lETER TRIcxivEss M1IATERIAr
0 ft 1 44 ft 61/4 1O SDR21 PVG
Company Name 16a INNEWCASING ORTUI3ING eo the rmsl closed4do
2.Well Construction Permit#: NA FROM I TO DLOWTER I TRICKhTM M1IATERIAL
List all applicable well construction permits(t.e.WC.Cotm V.State,Variance,etc.) ft. ft in
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM
EEI�T
pp y FROM TO I DIAMETER SLOT SIZE I TRICIINI•SS MATERIAL
x Agricultural oMunicipaUPublic ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. is
IndustriallCommercial 13Residential Water Supply(shared)
18:GROUT` .:
Irrigation FROM TO AIATERUL EMPLACEiIENrM1IEYHOD&AMOt NT
Non-Water Supply Well: o ft 20 M Holeplug Gravity 10 bags
Monitoring DRecovery & ft
Injection Well: ff. ft.
Aquifer Recharge DGroundwater Remediation -
19 SAND/GRAVEL'PACK ifa aicable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO M1IATEMAL EIIIPLACEMENT MOD
Aquifer Test [3Stormwater Drainage ft. fr.
Experimental Technology ElSubsidence Control ft i<•
Geothermal(Closed Loop) Tracer 30:DRILLING LOG;gi!ee additionahsheetsatnecess
FROM TO DESCRIPTION tolar,hardamsoiltnxk size.ete
Geothermal eaten Coolin Return Other(explain under#21 Remarks o % 18 ft- Clay/Shale
4.Date Well(s)Completed: Well ID#
5/4/23 NA Is ft 44 & Solid Rock
_
n, ft 77 ft Brown vein
Sa Well Location:
ft ft
Tony Surratt
ft ft
Facility/Owner Name Facility ID#(if applicable)
I
14201 Hwy 8. Lexington ft ft
it. ft. DWOSM
Physical Address,City,and Zip
Davidson 2l.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweU field,one Wong is sufficient) 22.Certification: n
35 39 8.364 N 8013 35.520 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary
By signing this form,1 Irereby certify that the wen(s)was(were)constructed in accordorre
7.Is this a repair to an existing well: []Yes or JNo with 15A NCAC 02C.0100 or I SA NCAC 02C.02o0 Well Construction Standards and that a
If this 1s a repair,fill out kno-t well construction a formation and explain the nature ofthe copy ofthis record has been provided to die well owner.
repair larder P21 remar/6 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 ofvvzils
construction details. You may also attach additional.pages ifnecessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depil's if0 ferent(example-3@200 and 2@100) 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 276994617
11.Borehole diameter: 6 Can.) 241L For Inicetion Well In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form 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
13a.Yield(gpm) 2 Method of test: weir 24c.For Water Supply&fniection Wells: In addition to sending the foul to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: chlorine Amount: 14 oz completion of well construction to the county health department of the county
where constructed.
Fonn oW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016