GW1--04198_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: ...........T----.
1.Well Contractor Information: ,.¢
Spencer Adams 14 WATER ZONES .,.
Well Contractor Name - FROM TO DESCRIPTION
4449-A 160 300 ft. a ens
280 f6 325 ut• z ew
NC Well Contractor Certification Number
15;UUTER:CASING(fort!inu1/34ssed'wells)OAIiINERGfap licdble) • _ .
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 159 fA 6114 i° SDR21 PVC
Company Name
2023—24445 . - `BANNERCASING-oItTUBING.(i eotuerm/alclesed=looji) . .
2.Weil Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consinie:ton permits(i.e.WC,Carroty:State,Variance,etc.) ft. ft. ie.
3.Well Use(check well use): R. fa In.
Water Supply Weft: FROM TO DIAMETER SLOT SIZE THICKNESS
MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) rpResidenlial Water Supply(single) rt. ft. to.
DIndustrial/Commercial DResidential Water Supply(shared) ,Alt GROUT -
("Irrigation : FROM TO MATERIAL EMPLACEMENT AIETHOD&.AMOUNT
Non-Water Supply Well: . o ft- 20 fo HOleplug GRavity 8 bags
QMonitoring Recovery ft. ft.
Injection Well: • ft. ft.
Aquifer Recharge.
• �Grotmdwater Remediatian _
19e:SANDIGRAVELPACK(if applicable)
Aquifer Storage and Recovery DSatinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft.
Experimental Technology OSubsidence Control fr. fa
Geothermal(Closed Loop) Tracer -20 DRU:I1NGZOG(att ch additionnl sheets ifaecesssip)" .
FROM TO DESCRIPTION(color,hardness,soilrock type,grain sue,etc.)
Geothermal(Heating/Cooling Rettrm) Other(explain under#21:Remazks) 0 m 30 ft. y
4.Date Well(s)Completed:616l23 Well um 2023-24445 30. fa 110 ft' Sandy overburden
5a.Well Location: no ft- 149 ft• Weathered rock 1
Debra Matheson 149 ft. 159 ft Sold rock
Facility/Owner Name Facility Wit(if applicable) 162 ft- •m fL brown rock
294 Skyuka Rd,Statesville 200 tt. 260 ft• brown veins
Physical Address,City,and Zip ft. ft. V;®Lt,fR: 't A f `1 9
Iredell 4733917144, 2t:REMARxs
County Parcel Identification No:(PAL)
JIJI 0 (.! 9fl23. .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: __; '' .
g / ..�. ,_..•..;r„ � r:t
(if well field,one lat/long is sufficient) ' 22.Certification: rt41,-„.;3i
35 44 40.911 N 80 5318.463 w 1 _— /
(4. ti.Qlz:�
6.1s(are)the well(s)JPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 12 No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
!Phis is a repair,fill out known well construction information and explain the nature oldie copy of this record has been provided to the well owner.
repair under 421 remarks 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 of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: 345 W) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3.1 00'and 20100') 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
II.Borehole diameter. 6 (in.) 24b.For Infection Wells: 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
(ie.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:Aids 24c.For Water Sunray&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: 16 eZ 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 Revised 2-22-2016 ,