GW1--08029_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 DESCRIPTION
4449-A 110 ft. 125 ft• 1.5 GPM
NC Well Contractor Certification Number 80o ft- 846 II' 2 5 GPM
IS.OUTER CASING(for multi-cased well.,)OR LINER(if cep llcable)
Rowan Well Drilling FROM TO DIAMETER M1 THICKNESS MATERIAL
cnmpaoyName 0 ft' 104 ft: 61/4 i4. SDR21 PVC
2023-32013 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC County,State,Variance,etc.) R R. i°'
3.Well Use(check well use): ft' R. to.
I
Water Supply17.SCREEN
Well; FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultmal DMunicipal/Public 0 ft• ft. in.
NGeothermal(Heating/Cooling Supply) x@Residential Water Supply(single) ft. ft. in.
Industrial/Commercial QResidential Water Supply(shared) 18.GROUT
Inigation _ FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n 20 1 Holeplug Gravity 18 bags
Monitoring DRecovesy R. ft. ,
Injection Well: ft. ft.
1111 Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
III, • 'er Storage and Recovery DSalinityBarrier FROM TO MATERIAL ' EMPLACEMENT METHOD
® • ••' Test DStonmwater Drainage ft ft.
•Experimental Technology 'DSubsidence Control R. ft.
I Geothermal(Closed Loop) DTmcer 20.DRILLING LOG(attach additional sheets if necessary)
•Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,basdaess mf/r«uctype,ar+sn sire,etc.)
0 a 20 - Red Clay ,
4.Date Wen(a)Completed: /3/23 Well>D#2023-32013 20 80 tz Sandy Overburden
Sa.Well Location: 80 ft* 94 ft' Weathered Rock
Holloway Family Builders 94 ft: 104 fL Solid Rock
Facility/Owner Name Facility JD#(if applicable) 110 R' 120 e' Brown Rock
144 Hickory Hollar Dr, Statesville 28625 •�a
�
ft. ft.
Physical Address,City,and Zip .
Iredell 3792 35 8002 21.REMARKS IDEC I ii 2023
County Parcel Identification No.(PIN)
5b.Latitude and longitude in d ees/niinutes/seconds or decimal degrees:
tnf3rre.y�n ?r•.. <. 3 i;r:t
> eSr ' P
(ifweli field,one tat/long is sufficient) 22.Ce cation: MN e.; �a
35 43 32.751 N 81 2 35.609 w AP-----'---
1( i.3 (z3
6.Is(are)the well(s){x Permanent or DTemporary Sigmtmc of ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or E)No with Mt NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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. 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 I GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i1"different(example-3(200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: ( ) Division of Water Resources,Information Processing Unit,
;water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addit In 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test:weir 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Dtstnfection type:chlorine Amount: 18 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
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