GW1--04977_Well Construction - GW1_20230807

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: .
Spencer Adams la.WATEltrzONEs:;
Well Contractor Name FROM TO DESCRIPTION
4449-A 400 ft, 410 ft i GPIs
NC Well Contractor Certification Number 450 ft 485 ft 4 oan
IS.OUTER CASING(for Intl!Weasedwells)OR LLNER(If ap 7icable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' '69 ft I
61/4 tn• I SDR21 PVC
27697 16.:7NNER CASING OR TUBING(geotheraial closed-loop)
2.Well Construction Permit if: 27697
' 'ro DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UiC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17r SCREEN_.,
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
! E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Ex Residential Water Supply(single)
ft. It in.
IndustriaUCommercial ()Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft. Hnleptug Gravity
Monitoring 0Recovery ft. ft.
Injection Well:
ft. ft.Aquifer Recharga ()Groundwater Remediation Aquifer Storage and Recovery Salinity Barrier '`19•SAND/GRAVEL PACK(ifappliicable) . ' - • •.. ;, •. ,-_
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20:DRILLING LOG(attach additional Sheets if necessary):_'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.Iiaednesa toillrocktvpe,gram sae etc.)
0 ft- 16 ft Clay
4.Date Well(s)Completed:7/21/23 Well II)#27697 16 f+• 65 ft
Sandy Overburden
5a.Well Location: ss ft 59 it. Weathered Rock
.Stratx Group 59 ft• 69 ft Sold Rock :. R o . 1 e r
Facility/Owner Name Facility ID#(if applicable) 78 ft* , ft. Brown Rock
615 Hoover Rd, Troutman ft. ft. AUG 0 j 2023
Physical Iredell Address,City,and Zip it rt if)F:.r;r�.�i'n 7r .00a:.�3 liri#
4741 469311 21.REMARKS:.;. . .. . l'W,S^., x.
County Parcel Identification No.(PIN).
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat./long is sufficient) 22.Certification:
35 42 14.144 N 80 52 13.162
W
7�'2 V 23
6.Is(are)the well(s)JPermanent or Temporary Signa of Certified well Contractor Date
By signing this fonm,I hereby temp that the ireli(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or QNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction intimation and explain the nature of the copy of this record has been provided to the well outer,
repair tinder ii21 remarks section or on the back ofthis 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/DP.T 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: 485 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifjarent(example-3@200'and 2@!00') construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
!firmer level is above casing,use"t-" 1617 Mall 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
I
13a.Yield(gpm) 5 Method of test: weir 24c.For Water Sunni,/&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: 1A lbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEn ironntental Quality-Division of Water Resources Revised 2-22-2016