GW1--08014_Well Construction - GW1_20231214

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCPIPiION
4449-A 180 ft• 200 D• 4 GPM
200 245 tt. 4 GPM I
NC Well Contractor Certification Number 15.OUTER CASING(for mniti cased wells)OR LINER(if ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 126 It 61/4 In' SDR21 PVC
384111 16.INNER CASING TUBING(geothermal dosed-loop)
2.Well Construction Permit fit -FROM TO DIAMETER THICKMSS MATERIAL
List all applicable well constractlonpennits(Le.UIC,County,Stale.Variance,etc) ft- fi. 'in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 0 ft. fc in.
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
Industrial/Commercial oResidentig Water Supply(shared)
18.GROUT..... -.
Irrigation FROM TO MATERIALEMPLACEMENT METHOD&AmouNr
Non-Water Supply Well: 0 ft 20 ft. Holeplug Gravity 15 bags
Monitoring °Recovery ft. ft.
Injection Well: f
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft. '
Experimental Technology }Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary).
Geothemmal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DFSCR ION color,birchen,sonhoehtmrpe,Mlle dee,etc.)
10/17/23 384111 0 � 20 � Red clay;
4.Date Well(s)Completed: Well ID# 20 100 Sandy Overburden
5a.Well Location: Imo ft' 116 ft' Weathered Rock
Brett Humphrey 116 ft 126 ft. Solid Rock
Facility/Owner Name Facility ID#(if applicable) 140 fl. 150 tt. Brown Rock
1145 Luther Ridge Lane, Mt Ulla 28125 ft. a Z .; ,,
Physical Address,City,and Zip ft. ft. t t' 2,a 1
Rowan 551 056 21.REMARKS. nF t-. 0 '. 2023
County Parcel Identification No.(PIN) it,i..e;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^c' : �^''-,"''fi''
(ifwell field,one lat/longis sufficient) 22.Certification: j
35 41 9.799 N 80 42 25.357 W • t ( 1 l—i 173
6.Is(are)the weU(s)jPermanent or QTemporarq Signature o Certified well Contractor I Date
By signing this form,I hereby certify that the ss ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or x°No with 15A NCAC 02C.0100 or 1SA 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 beenprovided to the ivell owner.
repair under MI remarks section or an 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 TOTALNUMBERofwells construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:265 (ft.) 24a.For All Wells: Submit this foil within 30 days of completion of well
For multiple wells list all depths if Afferent(example-3e 00'and2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter:6 (ln.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(ie.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)8 Method of test:Weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlorine 12 OZ the address(es) above, also submit one copy of this formwithin 30 days of
13b.Disinfection type:
Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22 2016