GW1--04211_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD WW-1) For Internal Use Only; mons. 7.,
1.Well Contractor Information:
Spencer Adams 14 WATERZONEs
FROM TO DESCRIPTION I
Well Contractor Name
160 ft. 100 n loom
4449-A
ft. It.
NC Well Contractor Certification Number 13;'OUTER CASING(for'wditi-caaed'weltn)`OR'LINEROlin &cable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 fb 132 ft' 6114 In* SORZ1 PVC
Company Name :16.1NIVERCASING OR.TUBING(giothet;mat closed-loop) '
2.Well Construction Permit#: 13707 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17 SCREEN .." .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) b Residential Water Supply(single) fL rt. in.
°Industrial/Commercial °Residential Water Supply(shared) 1.18 GROUT
Ilirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hoteptug Gravity 6 bags
Monitoring Recovery ft. it.
Injection Well:
ft. it.
°Aquifer Recharge °Groundwater Remediation t
<,19 SAND/GRAVEG'PACK(Ifappliiable)
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 2o:DRILLING'LOG(attectr:additionafaheets'ifaecessary) '::: r:
Geothermal(Heating/CoolingReturn) °Other(explain under#21 Remarks) FROM TO DESCR�7ION(cola,hardness soi!mcktype grain size,eta)
(
10 ft- 20 ft. clay
4.Date Well(s)Completed:6/2/23 Well IB#13707 20 ft• gp it' sandy overburden
Sa.Well Location: 90 ft. 122 ft" weathered rod( 1
Caruso Homes 122 ft. 132 ft said rod( s ,-,% r, ,,�...o. .,.m
Facility!DU(if applicable) 132 ft. 2e3 f6 brown rod(/chu '''m--�'' i kf 1,�,
FacilitylOwnerName PP )
5127 Kings Pinnacle Dr, Kings Mtn ft. rt.
ft. ft.
iiii 0 G 202�
Physical Address,City,and Zip
Gaston 3513021057 '.21iREMARKS. .> fn(` „t`';_^ Pr:� Y . ,. ::
County Parcel Identification No.(PIN) C'°+ i3: :
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. rtification:
35 11 24.337 N 81 18 30.156 w J�y� f 11-4....— te I L
6.Is(are)the wells)f)Perm anent or °Temporary Signature of Certified well Contractor Date 6
By signing this form,I hereby terrify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: °Yes or X°No with 1 SA NCAC 02C.0100 or 1SA NCAC 02C.0200►Veil Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 42l 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: 205 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi erent(example-3 00'and 2@100) 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
11.Borehole diameter. 6 (in.) 24b.For infection 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 above,
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:Airlift 24c.For Water Supply&Infection 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: to or • completion of well construction to the county(health department of the county
where constructed.
Rum GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016