GW1--08024_Well Construction - GW1_20231214

Print Form
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES i 1
FROM TO DESCRIPTION
Well Contractor Name 42 ft. 400 ft. 1 GPM
4449-A 560 ft- 585 ft. 5 GPM I
NC Well Contractor Certification Number 15.-OUTER CASING(for multi-cased wells)'OR LINER(if ap licable)
Rowan Well Drilling FROM _ TO DIAMETER I' THICKNESS MATERIAL .,
0 ft. 42 ft• 61/4 t"• SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:E H W23-00964 FROM TO DIAMETER ,I«s MATERIAL
List all applicable well construction permits(i.e.UIC,Connty.Stata Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
®Agricultural (DMunicipal/Public 0 t. ft. In.
R Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
R Industrial/Commercial DResidentisl Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL t EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Holeplug ' Gravity 16 bags
a Monitoring f l Recovery ft. ft.
Injection Well:
ft. ft.
I Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
ill Aquifer Storage and Recovery DSalinity Barrier -FROM TO MATERIAL! EMPLACEMENT METHOD
II Aquifer Test f Stonnwater Drainage ft. ft.
ill Experimental Technology OSubsidence Control R iL I,
•Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) •
FROM TO DESCRIPTION(color,hardness,eoWracktype,min size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 10 ft* Clay
4.Date Well(s)Completed:11/2/23 Well mD#EHW23-00964 10 n 18 ft weathered rock _ _
5a Well Location: 18 ft- 42 ft• solid rock
Tony Dellinger ft. ft.
Facility/Owner Name FacilityID#(if applicable) ft ft.
7645 Dellinger Rd, Denver 28037 f. ft. '`-t,_t,., .,j\V',A-
..„,....
Physical Address,City,and Zip ft ft.
Lincoln 32324 zl•REMARK OTC 1 /:. 7ffC
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Dal C.: rut St
(if well field,one lat/long is sufficient) 22. erdfieation:
35 32 3.793 N 80 58 59.227 W iL 1212.3
6.Is(are)the well(s)JPermanent or Temporary Signature of Certified Well Contractor Date
By signing this fort,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XONo with ISA NCAC 02C.0100 or ISA 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 to the well owner.
repair under#21 remarks section or on the back of this form. I,
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.
filled'1 SUBMTTTAL INSTRUCTIONS
1.
9.Total well depth below land surface:625 (ft) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(Qa 100) construction to the following' i
10.Static water level below topft
of casin •g• ( ) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ll,Borehole diameter:6 (in) 24b.For Infection 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: i
(i.e.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)6 Method of test:weir 24c.For Water Supply&Iniectio 1 Wells: In addition to sending the form to
chlorine 1.81bs the address(es) above, also submit Ione copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
- where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016