GW1--05876_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: - l'
Spencer Adams
Well Contractor Name FROM TO DESCRIPTION
4449-A 260 ft 290 ft .t 1174/1
300 h• 345 ft' a GPM'
NC Well Contractor Certification Number
151:0U1•ER CASING(for_malh cased webs)OR.I:INEIt{itap livable)
Rowan Well Drilling . FROM TO DIAMETER THICKNESS MATERIAL -
0 ft• 84 ft 614 in. SDR21 PVC
Company Name ."16:,INNER'CASING:OR TUBING(peotherdisl clesed-loop)
2.Well Construction Permit#:EHW22-0668rJ FROM , TO. DIAMETER T ICKNESS MATERIAL
List all applicable well construction permits(i.e.UlC County,State,Variance,etc.) ft• ft. ;; in.
3.Well Use(cheek well use): tt In. .
Water Supply Well: 1yiSCAEEN=`
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. ;in.
Geothermal(Heating/Cooling Supply) r3Residential Water Supply(single) ft in.
Industrial/Commercial ' °Residential Water Supply(shared) ::1&i.GROUI
.. -.
Irrigation FROM TO* MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: . 0 O• 20 ft Hate ug. Gravity 11 bags
Monitoring ElRecovery ft ft.
injection Well: ,
ft ft
Aquifer Recharge DGroundwater'Remediation 191SAND/GRAYELPAQC(if>tiipL'ceble)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft !'
'
Experimental Technology Subsidence Control ft ft, Ii ,
Geothermal(Closed Loop) E3Trar,er '2ti::DIBLINNO•1.OG(»ieehaadttioinatalieeb taticissary) _'
FROM TO DESCRIPTION(color,hardness,toUlrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft 22 ft Clay i
4.Date Wells)Completed:8/2/23well 1D#EHW2206685 22 ft• 74 ft Sandy Overburden
5a.Well Location: r< ft 84 h• Solid Rock
Caruso Homes ft ft.
Facility/Owner Name . . Facility ID#(if applicable) ft `- f7,,l
5017 Waterside Circle, Sherrills Ford tt• ft. t $L...t..?A.—
.Physical Address.City,andZip ft ft
Lincoln 29708 z1ItE11IARKS=
SEP 1 9 2023
County ParcelldentificationNo.(PIN) I' 1roorm^a,,.ic,rt Pr.^..1 ;�;xTa 1.1val
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DW 4' G
(ifwellfield one hal/bug is sufficient) 22. ertificafioo•
35 32 52.007 N 80 58 45.576 N, (� $ J 2- 1�3
6.Is(are)the well(s)iJx Permanent or Temporary Signature fCettified Well Contractor Date
By signing this form,I hereby certjy.that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 13 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 information and explain the nature of the copy of this record has been provided??the well owner.
repalrunder Till remarks section or on the back of this form. 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,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:w SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: 345 (R) 24a.For All Wells; Submit this form within 30 days of completion of well
Far multiple wells list all depths t(dii(Afferent(example-3(�00'and2@100) construction to the following: '
10.Static water level below top of casing: (rt.) Division of Water Resources,Information Processing Unit,
{twofer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L 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 is 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) 5 Method tritest:weir 24c.For Water Sunnis,&Injection Wells: In addition to sending the form to
the address(es)above, also submit one copy of this.form within 30 days of
113b.Disinfection type: Chlorine Amount: 16 of completion of well construction'to Ithe county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016