GW1--05871_Well Construction - GW1_20230912

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
4449-A •
Well Contractor Name FROM TO DESCRIPTION
110 ft 140 ft I Gm
Spencer Adams
290 ft. 325 ft 2 GPM
NC Well Contractor Certification Number
,15UTERVASING(ftutintilti4:Med:Welts)OR LINER(If.mi litable)'• ---.•:....i-: : ,
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 94 ft* 6 1/4 I: ilt SDR21 PVC
Company Name
-16aNNERVASINGOR TUBING(neotherinnt elcried-loOn)'.....'.''-,.,-''f.,---:-.-•'.:"..'.:..-• .
2.Well Construction Permit fit 341585
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.MC;County Stale,Variance,etc.) ft. ft• I la
3.Well Use(check well use): ft. ft. '. In.
•
Water Supply Well: 17 SCREEN
FROM ' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural r3Municipal/Public ft. ,ft. tn.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) lit:GRDDT.,.:;.::.:....,.,...,f......-,..,.....-,..:„.-:, 4.-.-:--,.:..::,.1...::::,:.....-,..::••,. :.._.-•_....::..,,,:.:., .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Hoteptug Gravity 7 bags
Monitoring EIRecovery ft. ft.
Injection Well: 1
ft. ft.
Aquifer Recharge r3Groundwater Remediation '
to,SAND1GRAVELPACK(if applicable).'':'.-.',-::-.::-._:•..,;:',.1.:.. ,.:':i.''.::.::.•?::-.,.: :'-...",.-.'Aquifer Storage and Recovery r3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• Aquifer Test DStormwater Drainage It. ft.
Experimental Technology °Subsidence Control ft. ft. l'
Geothermal(Closed Loop) °Tracer ;:20:BRILLING;LOG4sittaili addifitrantstitetnif ne—assir,j)i!...1,.,:r.-.':::,', .::.::-:.••,.:::.,:;*: ::-;•...,,•'S:•
TO DESCRIPTION(color,hankie's,soil/rack type.grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM
0 ft• 15 ft. Cray I !
Dv
4.Date Well(s)Completed:8/17/23 Well 341585
15 ft. 60 ft Sandy Overburden
5a.Well Location: 60 fL 94 ft. Quartz(weathered rock
Stacy Bryant 54 ft. 94 ft• Solid Rock
Facility/Owner Name Facility 113//(if applicable) 99 fe' 1,0 ft. Brown Rook
7), t..."—r•f77.7
16875 Dooley Rd, Cleveland 27013 160"- 170 ft' Brown Rock 1 %*.—..."44,./11..1 V li....,i
Physical Address,City,and Zip ft. ft. SFP 1 2 2023
Rowan 702 054
; , a Pr.,;:.
County Parcel Identification No.(PIN) Inftrirlicn :4-0,V4-41 Ur,
DINOAS OG
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 50 18.440 N 80 41 42.995
W
57 I I
'6.Is(are)the ivell(s)0Permanent or c3Temporary Signatureof Certified Well Contractor Date
By signing this form.I hereby cent&thatIdre ire/I(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or °No with I5ANCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature alike copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page ta 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 I.
9.Total well depth below land surface: 325 (fta) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-31fi200 and 2@i00) construction to the following: 1 •
I,
10.Static water level below top of casing: (IL) Division of Water Resourcps,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In additioIn 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 '
(i.e.auger,rotary,cable,direct push,etc.) . 'I
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test:weir 24c.For Water Suvptv&Infection'Wells: In addition to sending the form to
the address(es).abovei also submit One copy of this form within 30 days of
13b.Disinfection type: chlorine Amount; 15 02 completion of well construction to the'county health department of the county
where constructed. I
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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