GW1--05961_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: I •
1.Well Contractor Information:
Spencer Adams
FROSt TO DESCRIPTION-
Well Contractor.Name 115 ft. 125 ft a GPM
4449-A 260 ft. 270 it, 9 GPM I ;
NC Well Contractor Certification Number -15:;OITTERCASING(for.multi-casedivelis)`ORLiNER-(if:ep Gceble)..'
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
O It. 105 ft. 61/4 i m' SDR21 PVC
Company Name 16 INNER CASINGOR 7V131NG:(geothermal closed-loop):
2022000063 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
ft ft. � in.List all applicable well construction permits(i.e.UIG County.State,Variance,etc.)
ft, ft. l In,3.Well Use(check well use):
Water Supply Well: 17 SCREE111is• :.'::,;::.; :::,_:;:.r:::r
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Ej Agricultural DMunicipai/Public fr. ft. In.
©Geothermal(Heating/Cooling Supply) x3Residential Water Supply(single) (t, ft. ill•'
Dlndustrial/Commereial • °Residential Water Supply(shared)
fllrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fr zo ft. Holeptug; Gravity 9 bags
)Monitoring °Recovery ft. fr. '
Injection Well: fr. fr.Aquifer .Recharge �GroundtvaterRemediatioa :19:SAND/GRAVELPACKpf>applicable)
Aquifer Storage and Recovery �Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.G
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) °Tracer 2aDRIi.LINGLOGtauactiartdivaisn191+ri'e y)':ifneiesiM •• .-
!! FROM TO DESCRIPTION(color,hardness,sei0coek type,grain size,eta)
Geothermal(Heating/Cooling Return) riOther(explain under#21 Remarks) o ft 15 ti: Clay
4.Date Well(s)Completed:8/29123 Well ID#20220.00063 15 ft. 65 ft* Sandy Overburden
5a.Well Location: 65 ft* 95 f' Weathered Rock
Caleb Kaufman. 95 '� 105 fr Send Roar ' •C t:
Facitity'Owner Nano Facility ID11(if applicable) 115 ft la h' Brown Rock E P 2 2 �3
404 Liberty Church Rd,Thomasville 12511 190 it Very Fine sediments
ft. ft. Ifi(Ofit° fCi7 Prr...casto
Physical Address,City,and Zip
Davidson 21REMARKS:.;;:: :..,:. ;,::•;i .....:.: :...::. .. ::..:D5tti .E`
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 46 25.333 N 80 5 12.346 w 12qi 23
Signature of Certified Well Contractor Date
6.Is(are)the well(s)0Permanent or Temporary -
By signing this form,I hereby certify'that the Wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or DJ 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 aphis record has been provided to the well owner.
repair under P21 remarks section or on the back of this farm. 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 details. You may also attach additional pages if necessary.
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiWf rent(example-3 awl 00'and 2@l00) construction to the following: '
I
(tit.) Division of Water Resources,Information Processing Unit,
10,Static water level casibelng,
use top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing, "+"
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the fonmto 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: ` ,
(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
1
13a.Yield(gpm) 7 Method of test:V°1'. 24c.For Water Supply&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. j
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
Form GW-7 I
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