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HomeMy WebLinkAboutGW1--04978_Well Construction - GW1_20230807 Print Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: l Adams S encer Q Well Contractor Name FROM TO DESCRIPTION 4449-A 130 ft. 150 fr. 2 cm 240 ft, 300 ft* s mu NC Well Contractor Certification Number 15:OUTER-CASING(for:nU tIcased welts)OR LINER(if an & ble) . ' Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL 0 If 75 ft. 61/4 ID, SOR21 PVC Company Name 2023 25931 16..INNER CASING ORTUBING.(geotherMal closed-loop) .. 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. hi. Water Supply Well: 173SCREEN : FROM TO DIAMETER St.OT SIZE THICKNESS MATERIAL Agricultural Municipal/Public ft. ft, in. Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft- ft. in. Industrial/Commercial DResidential Water Supply(shared) 1ti,:GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non Water Supply Well: o ft. 20 ft. Hoteptug Gravity Monitoring EIRecovery ft. ft. Injection Well: ft. ft. Aquifer Recharge OGroundwater Remediation 9:SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test 0Stonmlater Drainage ft. ft. Experimental Technology E3Subsidence Control ft. ft. Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attachadd,hotial sheets ifnecessa y)'•: FROM TO DESCRIPTION(color,hardness,soiUmck type,grain size,etc.) Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) o ft 15 ft Clay 4.Date Well(s)Completed:7/25/23 Well um 202325931 15 ft. 85 ft' Sandy Overburden 5a.Well Location: '5 ft. 106 it Weathered Rock Brooks Henderson ton ft• 118 ft• Sold Rock r_ 6g r,, Facility/Owner Name Facility ID#(if applicable) 122 ft' ,b ft Brown Rock '\ ' .i ii.:i u si 349 Robinson Rd, Mooresville 137 r`• 160 fL brown broken rock AUG l 202 Physical Address,City,and Zip 160 ft• 225 fe• soft rock u Iredell 4638 04 2347 >211REMARRs'; ' County Parcel Identification No.(PIN) fat 1`Cx'3' a 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one 1at/long is sufficient) 22.Certification: 35 36 55.868 N 80 55 1.165 w . k"4„...4.---%_..—. eita....._—• "/ I st,S7.2 a 6.Is(arc)the wcll(s)0Permanent or Temporary signa of Certified Well Contractor Date By signing this form,I hereby certfy that the well(s)Mr(were)constructed in accordance 7.Is this a repair to an existing well: DYes or )No 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 h formation and explain the nature of the copy of this record has been provided to the well owner. repair wader#21 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 l 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: 305 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths Ifdilferent(example-3 a 200'and 2@100) construction to the following: 10.Static water level below top of casing: (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 Iniection 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) Method of test: weir 24c.For Water Supply& 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: 14 0zs completion of well construction to the county health department of the county where constructed. Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016