GW1--04214_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only
1.Well Contractor Information:
Spencer Adams 14:VVATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
240 ft. 260 ft. ecru 1
4449-A
rt. ft.
NC Well Contractor Certification Number
15:-017'1'ER'CASING(farmillh-cased:Wellit)OR'LINER(1f.Yp Leabie)..:.
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 184 IL 81/4 i°• SDR21 PVC
Company Name
r16 fNNER CASING OR:TUBING(tieothermal'elosed loop)
2.Well Construction Permit 0: 13997 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. In.
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgicultural DMunicipa1/Public ft. ft. In.
°Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
°Industrial/Commercial °Residential Water Supply(shared) .;,1s GROUT
'Urination FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 fL Holeptug Gravity 13 bags
Monitoring Recovery ft. ft.
Injection Well:Aquifer Recharge
rt. ft.[Groundwater Remediation
19 SANDIGRAVEL'-PACIE(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStomlwater Drainage ft. ft.Experimental Technology °Subsidence Control ft. TO
(Closed Loop) QTraeer -2O DRILLING LOG(atlacbadditional'sbeets ifneeevnry) ,`
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness, w surotk type,grain size,sect)
rL
0 18 ft. clay
4.Date Well(s)Completed:5/26/23 Well ID#13997 18 fL 170 iL sandy overburden
5a.Weil Location: rro ft- 184 fL solid rock
Caruso Homes 185 fL 240 fL brownrock
Facility/Owner Name Facility IDfl(if applicable) ft ft. ) :..z, v..4.'t ,¢°""
5013 Kings Pinnacle Dr, Kings Mtn ft ft. /^�
Physical Address,City,and Zip R. R. l:J U L 0 2023
Gaston 3513015520 2xRrtnRfcs
lrliiifS4G
County Parcel Identification No.(PIN) �1C CGx YL.y<,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce 'tication:
3511 19.050 N 81 18 27.106 Rm 4.Q.--/ 51?fie 123
6.Is(are)the well(s)0Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or 13 No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction informal ion and explain the nature of the 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I 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: 385 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3@200'and 2Ql00) construction to the following:
10.Static water level below top of casing:30 (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)6 Method of test:weir 24c.For Water Snooty&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: 18 m 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