GW1--04976_Well Construction - GW1_20230807

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FT Print Form ;1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
340 ft• 385 ft• 4 GPM
4449-A
ft. ft '
NC Well Contractor Certification Number '415..OUTEWCASING.(ffif multi:cased;wells).Olt LINER.(if ap'licable)..
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 75 ft• 6 1/4 in' SDR21 PVC
Company Name `
27696 16.'INNER,CASINGO11TUBING(geothermal closed loop), :`-,
2.Well Construction Permit#: 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): ft ft in.
Water Supply Well: '1,41:SCREEN ,,` . ,.. a.i_ .-:•-` : �.';. _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared)
"r18sGROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft Holeplug Gravity 8 Bags
Monitoring C3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation '119:SANK/GRAVEL PACK(if apphcable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
Aquifer Test 0Stormwater Drainage ft. ft.
• Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 ARILLINGLOG.(attackadditionsl'sheets-ifneeessary) .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soitlrocktype grain sae etc.)
0 ft. 15 ft• Clay
4.Date Well(s)Completed:7/21/23 Well mu27696 15 ft• 50 ft• Sandy overburden
5a.Well Location: so ft 65 ft Weathered Rock
Stratx Group 65 ft 75 ft Solid Rock 1- f.—(_"Fj 1 f- ,'�''"`)
Facility/Owner Name Facility ID#(if applicable) ft ft. t"" #`^�
625 Hoover Rd, Troutman ft ft. AUG U 7 2Q23
Physical Address,City,and Zip ft. ft.
Iredell 4741 46 7361 lr - P. ^ ` ut,
'21 REMARKS. sz� ���e�q-� s�:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C rtifreation:
35 42 13.932 N 80 52 13.735 W (1 1 z 23
6.Is(are)the well(s).JX Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we//(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [}No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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#2I 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-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 (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'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 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:
(i.e.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) 4 Method of test: weir 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also subniit'one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: 18 ozs 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