GW1--05904_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 .'i -
FROM TO DESCRIPTION
Well Contractor Name
120 ft. 140 ft- z arti
4449-A 260 ft 305 ft a on, j ;
NC Well Contractor Certification Number 15.'OUTER'CASING(for midti vaeed wells)OR:LINER(ifap 'habit)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. go ft 6114 is
Company Name 16.INNER CASING OR TIIBING:(iEeottrermal closed-loop) '
2.Well Construction Permit it:WE 106324 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le.(BC,County,State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): tit f' in.
17.SCREEN` . . - .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
III Agricultural NI Municipal/Public tt ft. :in.
al Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. rt. !in.
N Industrial/Commercial E3Residential Water Supply(shared) .18:GROUT . .
" Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holepiug Gravity 16 bags
ll Monitoring DRecovery ft. ft.
Injection Well: ft. ft. •
IN Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(ifsppliceble)-- ' •
I Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ill Aquifer Test DStormwater Drainage ft ft.
ijll Experimental Technology DSubsidence Control ft ft f
a Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheet if necessary): . . .
FROM TO DESCRIPTION(color,hardness,soli/rock type,grain sae,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft- 10 Clay
4.Date-Well(s)Completed:8/4/23 Well ID#WE106324 10 it. 60 fr" Sanity Overburden
5a.Well Location: co it 80 ft Weathered Rock
Rufus Dalton - 80 rt 90 K. Solid Rock _
t•�� \
Facility/Owner Name' FacilityID#(if appGcable) 90 ft. rm ft. Soft Rock r t V
188 Iron Gate Circle,Mooresville 28117 120 f. 145 ft Quartz Vein
ft. ft. SEP 1 2 2023
Physical Address,City,and Zip
464515 6945 21:REMARKS ' �.
Iredelll7flaf^f1 Nr,.- �,
ft1t
�� Parcel Identification No.(PIN) Ewer,�`�,G
ty rnur
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/king is sufficient) 22.Certification:
35 32 14.888 N 80 52 35.698 W i1 - g i q i 23
Signature (Certified Well Contractor' ` Date
6.Is(are)the wcll(s)i0x Per anent or DTemporary 1
By signing this form,I hereby cerilty that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ©X 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 itrfomrationand explain the nature of the 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:
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 if necessary.
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (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: ','
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy'of;this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test:weir 24e.For Water Sootily&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: completion of well construction to the county health department of the county
where constructed.
Form OW-r North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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