GW1--08025_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 I
FROM TO DESCRIPTIONI
Well Contractor Name 110 ft. 140 `� 70GPM I
4449-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for malts-eased wens)OR LINER Of ap livable)
Rowan Well Drilling FROM TO DIAMETER ' 'THICKNESS MATERIAL
0 ft. 83 ft. 61/4 " SDR21 PVC
Company Name
OSWP202335904 16.IINNERCSIINGORTUBIN (geot DIAMETER hermal )
2.Well Construction Permit fir FROM
MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) it ft. In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural }Municipal/Public 0 ft. ft. to. I
Geothermal(Heating/Cooling Supply) X� )Residential Water Supply(single) ft. ft In.
Industrial/Commercial DRoeidential Water Supply(shared) 18.GROUT
_.. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 7 bags
Monitoring flRecovery et. ft..
Injection Well: ft. , ft,
Aquifer.Recharge QGrotmdwaterRemediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I . EMPLACEMENTMETHOD
Aquifer Test QStormwater Drainage ft. ft. I
Experimental Technology QSubsidence Control ft. ft. 1
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG(attach additional sheets If necessary)
(explain under#21 Remarks) FROM TO DESCRIPTION(cuter.harder,sonfroektype,sin elm,etc.)
Geothermal(HeatinglCooling Return) Other 0 ft. 20 ft Clay 1
4.Date Well(s)Completed:10/19/23 Well m0202335904 20 ft 40 ft. Sandy dierburden
5a.Well Location: 40 ft. 73 e• Weathered Rock
Northlake Developers 73 f4 83 ft: Solid Rock
Facility/Owner Name Facility T#(ifappliceble) ft. ft.
232 Kenway Loop, Mooresville 28117 f. ft.
ft. ft. ''-.-., am' :.a -,. i
Physical Address,City,and Zip k'1, . .,,; '1; i m
iredell 4639 415759 21.REMAR1s
County Pascal Identification No.
(PIN)
Dr C 1 i 2023
51.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ! r. :„:;.
(if well field,one latflongissufficient) 22.f rtilicatlon: . lf'i'!"2 cn P ^^�`. 1:E1
tG`i l �r 35 38 8.968 N 80 54 9.623 w z3
6.Is(are)the well(s)13Permanent or QTemporary
Signature of Certified Well Contractor Date
By signing this fora I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existingwel: QYes or XQNo with RSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill our bum:well construction information and explain the nature ofthe COPY of this recordhas:been Provided to the well owner.
repair wider#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back oft is page to provide additional well site details or well
construction details:You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (&) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'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 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (ID) 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 1
(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 276991636
13a.Yield(gpm) 10 Method of test:Weir 24c.For Water Sunplv&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type:chlorine Amount:9 oZ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016