GW1--05956_Well Construction - GW1_20230912

IPrint Form I
WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES • I
FROM TO DESCRIPTION
Well Contractor Name 380 ft 405 ft: a).CPU
4449-A ft. ft.
NC Well Contractor Certification.Number 15.OUTER CASING(formulti=cased wells)OR LINER(if up llcable)
Rowan Well Drilling FROM . TO DIAMETER'' ' THICKNESS MATERIAL
0 ft 55 ' ft, 61/4 1In. SDr21 PVc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2022000045 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr, tr. in.List all applicable well construction permits(i.e.U1C,County,State.Variance,etc.)
ft. ft. I in.
3.Well Use(check welt use):
17.SCREEN •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) [L ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT '
FROM TO MATERIAL EMPLACEMENT h1E'IIrOD&AMOUNT
Irrigation p ft. 20 ft' Holeplug Gravity 18 bags
Non-Water Supply Well:
Monitoring Recovery ft ft.
injection Well: ft ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
Stotlnwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) I Tracer 20.DRILLING LOG(attach adattioni+i sheets If necessary)
•
FROM TO DESCRIPTION(odor,hardness.soiFwck type,grain stra etc.)
Geothermal(Heating/Cooling Return) Other(eiiplain under#21 Remarks) 0 ft 12 fr. Clay I
4.Date Well(s)Completed:8/30/23 Well ID#2022000045 12 ft. 35 ft' Sandy Overburden
ss ft' 45 ft. Weathered Rock
5a.Weli Location:
Rodney Metters 45 fL 55 ft• Solid Rock
3885 ft. ass ft' Major Fracture •+"" '�+•!; '•
Facility/Owner Name Facility ID11(ifappliralilc) t-'� Ili
455yountz Rd,Lexington 27292 ft. ft 3� ��'
rt.
Address,
City,and Zip
DavidsonDa23
vdsoo21.REMARKS JC?n ^� y
County Parcel Identification No.(PIN) , lrl�••,. t
, ? G u
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .Certification:
(if well field,one tat/long is sufficient)
35 4818.122 N 80 11 37.064 �t ) ,....I.D.:....,,...._. 11 j 30/23
Signe of Certified Well Contractor 1 Date
6.Is(are)the well(s)1jPermanent or QTemporary
By signing this form../hereby cent&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ()No with 15A NCAC 02C.0100 or 15A 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 to tin:well owner.
repair under r21 remarks section or on the back aphis 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 1 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: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijd(erent(example-3 a 200'and 2Qa 100) construction to the following:
10ft. Division of Water Resources,Information Processing Unit,
If ter lev water level below top of casing: ( ) 1617 Mail Service Center,Raleigh,NC 27699-1617
Ijwater lever is above casing,use"+" i 1
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,misty,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
Method of test:weir 24c.For Water Sumily&Infection Wells: In addition to sending the form to
13a.Yield(gpm) 40} the address(es) above, also submit one copy of this form within 30 days of
chlorine Amount: 19 oz completion of well construction to the county health department of the county
136 Dtsiofection type where constructed. I
Form OW-I North Carolina Department of Environmental Quality Division of Water Resources Revised 2 22-2016