GW1--08023_Well Construction - GW1_20231214

Print Form. - I
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATERZONES I
Well Contractor Name FROM TO • DESCRIPTION
4449-A 380 ft 400 ft 5 GPM 1
ft ft.
NC WeII Connector Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(if ap nestle)
Rowan Well Drilling FROM TO DIAMETER{ THICKNESS MATERIAL
0 ft ,83 fir. 61/4 I" SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:�SWP202331508 FROM TO DIAMETER THICENTSS MATERIAL
List all applicable well construction permits(Le.UIC,County State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO .DIAMETER SLOT SUE THICKNESS MATERIAL
()Agricultural QMunicipal/Public 0 ft. ft. in.
]Geothermal(Heating/Cooling Supply) %()Residential Water Supply(single) g, ft in.
Dlndusti al/Commercial ()Residential 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:
Aquifer Recharge QGroundwaterRemediation
19.SAND/GRAVEL PACK Of applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO - MATERIAL' EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage fl. ft
DExpenmental Technology ()Subsidence Control ft. ft.
a Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
()Geothermal(Heating/Cooling Return) ()Other(explain under#21 Remarks) FROM TO DESCRIPTION(eolo;hudaem,wt1/ructt,pe,grain ctu,etc.)
ft ft- Clay
4.Date Well(s)Completed:10/20/23 Well m#202331508 0 it 40 tt Sandy overburden
5a.Well Location: 40 R' 73 ft' Weathered Rock
Northlake Developers 73 ft 83 ft. Solid Rock
Facility/Owner Name Facility lD#(if applicable) ft. ft.
260 Kenway Loop, Mooresville 28117 ft ft. _.4 ,�
Physical Address,City,and Zip ft. ft Z�'r
lredell 4639 41 1373 21.REMARKS DFZ 1 ,: 2923
County Parcel Identification No.(MN) 11,1'4..4 :ova
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C'',1v-' ` riPQ Uiz
(ifwell field,one lat/long is sufficient) 22.Certification:
35 38 3.790 N 80 54 13.965 W I , F o 1zb 123
6.Is(are)the wel(s)4)Permanent or ()Temporary Signature of Certified Well Contractor Date
By signing this fora,I hereby cent that the well(:)an,(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or QNo with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction htformation and explain the nature of the copy of this record has beet provided to the well owner.
repair under#2I remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For.GeoprobelDPT or Closed-Loop Geothermal Wells having the same
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 1
9.Total well depth below land surface:405 ( ) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2Q100) construction to the following:
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 On.) 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a Yield(gpm)5. Method of test:weir Z4c.For Water Snuuly&Injection I 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•. 19 OZ completion of well construction to the county health department of the county
where constructed.
Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016