GW1--05903_Well Construction - GW1_20230912

j : Print'Form m:`:>
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
r
Spencer Adams 14..WATERZONFS..1.;:: <:i
FROM TO DESCRIPTION
Well Contractor Name
120 ft. 140 ft. z aPu 1
4449-A -
260 it. 305 fL 5 GPM 1
NC Well Contractor Certification Number ?15:OUTERCASING`(for..multi-easedlwells)OR LiNER'(ifap'Hubble)-'.'
Rowan Well Drilling FROM To DIAMETER THICKNESS MATERIAL
0 ft. 90 ft. 61/4 i m SDR21 PVC
Company Name •WE 106324 16.INNER`,CASING ORTU8ING(eeotbermaI closed-loop) '. :.
2.Well Construction Permit#: FROM , ' TO DIAMETER THICKNESS MATERIAL
List all applicable well constntction permits(i.e.UIC,County,State,Variance,etc) ft .i ft. in.
3.Well Use(check well use): ft. 1 It. On.
Water Supply Well: FROMREE TO)..,, DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) R. ft. in.
industrial/Commerciai OResidential Water Supply(shared) '.t8:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 fL Holeplu9 Gravity 16 bags
Monitoring (Recovery ft. ft.
Injection Well: ft. ftI
Aquifer Recharge E3Groundwater Remediation
=19sSAND/GRAVEL'PACK(Ifapphcable).'' : _
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. .
Experimental Technology E3Subsidence Control ft. ft.
i
Geothermal(Closed Loop) OTracer •20 DRILLING:LOG(attsetiadditi(intsheetsifurcans :) .. .
FROM TO DESCRIPTION(color,hardness,soittrock type.grain size,etc.)
Geothermal ool(Hearin$(Cing Return) (exp
lain( lain under#21 Remarks)
0 ft• to ft. clay
4.Date Well(s)Completed:8/4/23 Well milWE 106324 10 ft. 60 ft. Sandy overburden
5a.Well Location: m ft. 80 ft. Weathered Rock
Rufus Dalton 80 ft- 90 n Solid Rock
90 ft. uo ft. Soft Rock i ti..r it, '+ 1""C
Facility/Owner Name Facility m#(if applicable) �Z ti...
188 Iron Gate Circle, Mooresville 120 f. 145 ft. �-'' '' �"`L)
Quartz Vein
Physical Address,City,and Zip ft. ft. S E P i
Iredell 464515 6945 :21:REMARKS
$0 0rrr.afderi r"sf-t .4,44:q t.lr1
County Parcel Identification No.(PIN) r,.�1,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. rtiflcation: j J
35 32 14.888 N 80 52 35.698 W . 4.(2.........._ ! t4 1 Z3
6.Is(are)the well(s)JPerinanent or Elremporary Signature o Certified Well Contractor Date
By signing this form,1 hereby cent&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or }}No with ISA NCAC 02C.0100 or ISA hCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fllf out known well construction infonnation and explain the nature of the copy of this record has been provided to the well owner.
repair-under#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 I 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 Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths.iifdderent(example-3@200'and 2@100) construction to the following: 1
1 I
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 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
Rotary above,also submit one copy of this;form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(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 Suimly&Infection 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: completion of well construction to the county health department of the county
where constructed.
I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016