GW1--05962_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I r"�
1.Well Contractor Information:
Spencer Adams 1437WATER4ZONE$ _ Y s'< • "V + s-i ,.0.r.-,? . ._... ti.,,
Well Contractor Name FROM TO DESCRIPTION
126 ft- 160 ft 2 cru i
4449-A i
370 ft 400 ft a GPM
NC Well Contractor Certification Number ;15 OUTER'CASING:(for`multi-ciiaed;wells)OR LINER(if ap licable);= Vr:1, •
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft* 126 H. 61/4 I in' SDR21 PVC
Company Name I6c`INNER CASING:OR'TUBING(geothermal closed-loop)" `% '
2.Well Construction Permit#:2022000053 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '17 SCREEN ,c,-4 •=y .i ,., _ r ,:,u,>'n
FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. . in., •
Geothermal(Heating/Cooling Supply) x3Residential Water Supply(single) ft ft is
Industrial/Commercial DResidential Water Supply(shared)
18,GROUT 1 ' n , 1 w'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Holeplug Gravity 27
Monitoring • f Recovery ft. ft. !
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation ;:19:SAND/GRAVEL'PACK(if apilicable) "t
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fDStormwater Drainage ft ft i'
Experimental Technology OSubsidence Control ft. ft. I:
Geothermal(Closed Loop) OTracer ;20:DR11LINGLOG:(attachadditionalafieets.ifvecesaary')e, & .04: ...�... ; .;.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type.grain size,etc.)
0 ft 20 ft Hard Clay
4.Date Well(s)Completed:8/25/23 Well ID#2022000053 20 ft 80 ft Sandy Overburden
• 5a.Well Location: so ft' 116 ft Weathered Rock
• Tiger Dog Builder 116 ft 126 ft• Solid Rock
Facility/Owner Name Facility IV/(if applicable) 160 ft* 16e ft• Brown Rock �i..,.C y% f °("'�
409 Sierra Trace Rd, Denton . ft ft. � `" ' 7 LI
Physical Address,City,and Zip ft. ft. S E P 1 2 2023
Davidson ,21 REMARKS„:"+ ,-.. t . t ° e.A t z:`z .N
County Parcel IdentificationNo.(PIN) lfW�t.ii :/Ci1 r�r.^n;rPl+t<'��tf
G u1't`tal
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
`.::l+a• (if well field,one lat/long is sufficient) 22. ertification: A
35 36 25.078 N 80 13 22.356 Nr
• v 8 1123
6.Is(are)the well(s)4% Permanent or Temporary Signature of Certified Well Contractor ; Date
By signing this form,1 hereby certiry 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 toi 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 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: 425 (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:
i
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
Ifwater 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
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,1Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test:weir 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: 20 eZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , 1 Revised 2-22-2016