GW1--08021_Well Construction - GW1_20231214

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Print Form:;::: .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well ConhactorNanm FROM TO DESCRIPTION
4449-A 290 fw 345 ft: 6 GPM
ft. ft I
NC Well Contractor Certification Number 15.OUTER CASING(for mold-cased wells)OR LINER(If a cable)
Rowan Well Drilling FROM TO D . THICKNESS MATERIAL
Company Name 0 ft 28 6114!. I°• SDR21 PVC
391756 16.INNER CASING ORTUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TmCKNPSs MATERIAL
List all applicable well construction permits(t e.VIC County,State,Variance.et-.) ft ft. . In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
gricultura) EMunicipal/Publicc 0 ft ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Holeplug Gravity 8 bags
Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
AquiferRecharge DGioondwater Remediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test .fjStormwater Drainage R R I
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Experimental Technology OSubsidence Control it. ft. I
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets Knecessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(ea or,hardness adUrock type,wain size,etc.)
0 tl: 15 - Clay I
4.Date Well(s)Completed:11/7123 Well m#391756 15 ft• 28 Solid Rock
Sa.WeRZocation: ft ft.
Mason Beck it. ft. --*is% .,. T. F
Facility/Owner Name Facility UM(ifapplicable) ft' ft. " "'� `,0 ft---.fi_._- @,i d ,)_y,'
0 Old US HWY 70, Cleveland 27013 ft ft.and Zip ft. f EC t i
Physical Address,City, ft.Rowan 270 129 21.REMARKS
lne;,r,:r,�:!gin �� r :202)�
County DWQ p 7 ��a
Parcel Identificatioallo.(PIN)
Sb.Latitude and longitude in degrees/mimntes/seconds or decimal degrees:
(ifweu field,one tat/long is sufficient) 22.Ce cation: 2L(L)......,
35 43 41.256 N 80 39 10.273 W
I l 1-7 )23
6.Is(are)the well(s) Permanent or E3Temporary Signature o Certified Well Contractor Date
signing this ores I here
by eby rzrtb,that the x+eA(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or QNo with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown xvll construction information and explain the nature of the ccp9 of this recordhas 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:
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 TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35 (ft) 24a.For MI Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(0200'and2©100' construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Proroeaing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: construction above,also submit one copy of this'form within 30 days of completion of well
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
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13a.Yield(gpm)6 Method of test:weir 24c.For Water Saintly.Sc Iniection Wells: In addition to sending the form to
the addresses) above, also submit Ione copy of this form within 30 days of
13b.Disinfection type:chlorine Amount: 16 oz 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 Revised 2-22-2016