GW1--04206_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: !
Spencer Adams
I4:YVATER ZONiFS - .. •.,.. .. ,
FROM TO DESCRIPTION '
Well Contractor Name
140 ft. 155 ft. taunt
4449-A
ft. ft.
NC Well ContractorCettificationNnmber .:1S'oI1TERCASING(fofmulti.ased-wells)011LINER(if'ip ll able)
Rowan Weil Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 112 ft* 81/4 in• SDR21 PVC
Company Name
16.INNER irASiNG.OR TUBING fgeotheramal dertiddoop)
2.Well Construction Permit#: 13998 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): iL ft in,
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft ft in. .
Industrial/Conunercial ()Residential Water Supply(shared) IS GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft Z0 ft Heleplug Gravity 21 bags
Monitoring ORecovery ft rt.
Injection Well: ft ft ,
Aquifer Recharge ()Groundwater Remediation
:.19:SANDIGRAVEL'PACK(ifapplicable) '
Aquifer Storage and Recovery DSallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft
Experimental Technology ()Subsidence Control ft. ft '
Geothermal(Closed Loop) ()Tracer :,20.DRILLINGLOGi(attach additional sheets ifueceasary;::: • . =.:
FROM TO DESCRIPTION(color,hardness,soiirack type,grain Size,etc.)
Geothermal(Heating/Cooling Return) rlOther(explain under ti21 Remarks) 0 ft 19 ft day
4.Date Well(s)Completed:5/31/23 Well ID#13998 19 it' 70 ft• sandy overburden 1 6'r'R r.,i j�.t��.
Sa.Well Location: 70tt 102 ft weathered roar �"f 's rt •i '
/� lam'
Caruso Homes 102 ft 112 ft solid rock fill 79 g ,023
t
Facility/Owner Name Facility lD#(iifapplicable) 113 ft• IX' it. brown frachxe 79 .
111Y�ti.T.;,.;a��T;rc...
5101 Kings Pinnacle Dr,Kings Mtn 140 ft 155` fracture 10 GPM rock n a_�, a Ur .
ft ft ( 4,��t+.d
Physical Address,City,and Zip
Gaston 3513015799 27_IiE1HAR[iS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification: v
3511 22.551 81 18 26.797
N W ii. 01 31 I2a
6.Is(are)the well(s)OPermanent or Temporary
SignatureofCertifiedWeltContractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or .f21 No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well miner.
repair under 421 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
S.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 details. You may also attach additional pages if necessary,
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
205.
9.Total well depth below land surface: 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di(ferent(example-3()200'and 20i100) construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in) 24b.For Injection 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:
(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) 10 Method of test Welt 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
13b.Disinfection type: Chlorine Amount: 10oz 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