GW1--04978_Well Construction - GW1_20230807

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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