GW1--04974_Well Construction - GW1_20230807

:'1.Pri`nt form f-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Contractor Information:
Spencer Adams -14.WATER'ZONES ..:- :..-:•.r • •.,...
Well Contractor Name FROM TO DESCRIPTION
4449-A 440 ft, 505 ft. ,can
ft. ft.
NC Well Contractor Certification Number 15.OUTERCASING(for;niulti-cased'.wells)OR LINER(if tip ttcabte)`. .
Rowan Well Drilling . FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 74 ft. 61/4 in' S01221 PVC
Company Name
2023-14888 16.INNERCASINGOR TUBING(gcothermalClosed-loony .'.
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,.County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft, ft. In.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TIHCKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) �X Residential Water Supply(single) ft ft in.
Industrial/Commercial OResidential Water Supply(shared)
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ff. 20 ft. Hoieplua Gravity 8
Monitoring )Recovery ft. ff.
Injection Well:
ft. ft.
Aquifer Recharge EjGroundwater Remediation
•19:SAND/GRAVEL PACK(if applicable) ':.'' '
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormweter Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.:DRILLING:LOG(attiaehedditionalMiceli Ifibeessary). y,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sofl/rock type,{rain size,etc.)
0 ft. t2 ft. Clay 1 I
4.Date Well(s)Completed:7/19/23 Well Kw 202314888 12 fr• so tt. Sandy overburden
5a.Well Location: 50 ft. 64 ft. Weathered Rock ra i ' ®i re——a)
Stratx Group 64 ft• 74 ft. Solid Roth I \ L'1.► V l
Facility/Owner Name Facility ID#(if applicable) 78 ft. ee ft. Brown vein AUG 1 7 2023
639 Hoover Rd, Troutman 95 ft. 105 ff. Brown vein dP
Physical Address,City,and Zip ft. ft. iflivv:7Yii�l I1 Pff.,- S.64,::',. Ut;is
Iredell 4741 46 7114 21:'REniARKS. t3�':; :_,
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
35 42 12.810 N 80 52 14.778 W ) _i\i,,z,.....R.._,____,. 451....\______
--) j,q 1 z3
6.Is(are)the well(s) Permanent or ®Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby cerlh'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or ENo with ISA NCAC 02C.0100 or 75A NCAC,Q2C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under ii21 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 I GW-I 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: 505 (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@200'and 2@I00) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is abase 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
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) 3 Method of test: weir 24c.For Water Supply&iniection Wells: In addition to sending the form to
• the address(es) above, also submit one copy of this form within 30 days.of
chlorine 1.5lbs completion of well construction to the countyhealth department of the
13b.Disinfection type: Amount: P P county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016