GW1--05902_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
4449-A
Well Contractor Name FROM TO DESCRIPTION - -
130 f
Spencer Adams 110 ita ,
NC Well Contractor Certification Number 300 ft 345 ft. er+n
i
l&OUTERCASING(formulti=easedwelli)ORLINER'.(ifin'1i66ley::::_: - -Rowan Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL 67 ft I 61/4 I la' SDR21 PVC
t�$W0202331006 :16:INNER CASING OR TUBING 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, 1 in.
3.Well Use(check well use): ft. ft in.
Water Supply Well:
Agricultural ' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft in
Geothermal(Heating/Cooling Supply) Ex Residential Water Supply(single)
ft, it. in.
Industrial/Commercial E3Residential Water Supply(shared)
Irrigation
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o 20 ft
Holeptug Gravity 14 bags
Monitoring °Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation fa ft. 1
Aquifer Storage and Recovery Salinity Farrier -19.SAND/GRAVEL•PACK(ifappite:161.: : - .,..?;-:.:* •> -
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft. i
Experimental Technology °Subsidence Control ft ft
Geothermal(Closed Loop) Tracer • �20:- I'
- ;DRII;T:INGLOG(attacfiaddirioniitlafieebifiiieessatar):::
L Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saNmcktype Quin vie,etc.)
0 ft. 20 ft. Clay I I
4.Date Well(s)Completed:8/10/23 Well m#oswp202331006 20 ft 40 it
Sandy Overburden
5a.Well Location: +o ft. 57 ft' weathered rock
Northlake Developer 57 ft. 67 it• Sold Rock 5 ` i...G I..,1 j
FacilitylCnvnerName FadilitylDl/(if applicable) 75 ft co ft. Brown rock
141 Trellis Lane,Troutman 170 f` 200 ft. Brown rock S L N 1 2 ZOZ:
Physical Address,City,and Zip ft. ft.
rM R� Pr- e . 1.0411
Iredell 4741 21 6536 `:2LREMARKS•.:•:: =.r::`.:•>::>:--....::;:::-:: In:. . .• ,
County Parcel identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 41 25.959 N 80 52 37.885
NV
AreQ____
'C (a [23
6.Is(are)the weil x(s) Permanent or Temporary Signal a of Certified Well Contractor 1 Date.._....__
ateI
f •
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or I2 No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known w•e//construction h formation and explain the nature ofthe copy of this record has been provided to t m wet/owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You.may also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:h
SUBMITTAL INSTRUCTIONS
345
9.Total well depth below land surface: (f<-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@200'and 2@100')
construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resour If water level is above casing,use"+"
Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
•
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test:Weir 24c.For Water Sunnly&inlection Wells: In addition to sending the form to
chlorine 16 oz the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016