GW1--05863_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
. 55 ft. 70 ft. a cuss I 4
I
4449-A
300 ft. 400 ft. is cren
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if an licable)
Rowan Well Drilling FROM TO - DIAMETER THICKNESS MATERIAL
0 ft. 45 ft• 61/4 '' in• SDr21 PVc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Weil Construction Permit#:
395983 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i,e.UIC,County,State,Variance,etc) ft. ft. 1, in.
3.Well Use(check well use): It ft. in.
Water Supply Well: 17.SCREEN'PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ['Municipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) [['Residential Water Supply(single) ft. ft in. .
Industrial/Commercial ['Residential Water Supply(shared) is.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 ft. Y0 ft. Holephig Gravity 8 bags
Monitoring ['Recovery ft. ft.
Injection Welk ft. ft. ,
Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) •
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ['Stormwater Drainage ft. ft.
Experimental Technology [Subsidence Control ft ft. I
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary) - •
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) o ft 15 ff• Clay
4.Date Well(s)Completed:8/18/23 Well ID#395983 15 ft• 35 ft• sandy Gay'
5a.Well Location: u ft. 45 ft. Solid Grabite
Debbie Potts 56 ft- 7s ft Vein I Fracture
Facility/Owner Name Facility ID#(if applicable) ft It a t.,,r4 C,?E I ' "N'i
1675 NC 801 Hwy,Woodelaf 27054 ft. ft. "--L#A...t' k• L.,
Physical Address.City,and Zip it ft. S F P 1 2 2 0 2 3
Rowan 806 017 21.REMARKS
CountyParcel Identification No..(PIN) :I ilSiu:tt"+:(C 1 Pr,T-. • ,9:4 1.r::
Iry L:: a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Certification:
35 47 6.214 N 80 34 27.220 �, i ip , a-I l Q
tom.
6.Is(are)the well(s)0Permanent or ['Temporary
Signatur of Certified Well Contractor Date
By signing this form,I hereby cent),that the well(s)was(were)constructed in accordance
7.Is this a repair town existing well: Dyes or x['No with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction Information and explain the,nature oft/re copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
8.For Geoprohe/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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft-) 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: j
10.Static water level below top of casing:50 (tt.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
I.
• 11.Borehole diameter: 6 (in.) 24h.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) 3 Method of test:Weir 24c.For Water Sunniv&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: 20 or completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016