GW1--08044_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
FROM TO DESCRIPTION
Well Contractor Name 126 ft 200 ft- 1 GPM
4449-A 300 m 330 ft 4 GPM
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 126 f. 61/4 ;In- SDR21 PVC
CompanyName GRIMING 16.INNER CASING GRTING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennUs(i.e.UlC,County,State,Variance,eta) ft ft In.
3.Well Use(check well use): ft. : ft. In.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Agricultural LMunicipal/Public 0 ft: ft. In.
()Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. In.
DlndustriallCommett ial E3Residential Water Supply(shared) 18.GROUT .
fhrrigation FROM TO MATERIAL METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 • ft Holeplug Gravity 34 bags
Monitoring ()Recovery ft ft
Injection Well: ft ft.
Aquifer Recharge ()Groundwater Remediation 19.SAND/GIZAVEI.PACK(if:makable)Aquifer Storage and Recovery Salinity Barrier FROM TO - MATERIAL EMPLACEMENr1m9SrHOD
Aquifer Test ()Stor mwater Drainage ft.
ft.Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLINGLOG(attach additions]ebeetsIfneee�sary)
FROM TO DESCRIP[ION(color,hudum.soulrack Me,grain rice,etc.)Geothermal(IieatinglCoolfng Return) ()Other(explainunder#21 Remarks) 0 ft- 20 ` ft- Clay
4.Date Well(s)Completed:11/8/23 Well ID#40.0043 20 ft 85 ft' Sandy,Overburden
5a.Well Location: 85 ft 116 ft Weathered Rock
Danyel James 116 ft 126. ft.. Solid Granite - -
FacilitylOwnerName Facility IINR(if applicable)
130 ft 180 ft Soft Granite 't i `j ._
0 Deadmon Rd, Mocksville 27028 ft . ft.
uf ,. 1 r 211:3
ft ft:
Physical Address,City,and Zip
REMARKS 21. � o Ll'a
Davie lnr:.,,r,._:..:; � .` "� ;'
County Famel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
35 53 3.086 N 80 32 4.357 w I( i g 1 z,3
Signature of Certified:Well Contractor Date
6.Is(are)the well(s)0Permanent or ()Temporary
13y signing this form,I hereby certi that the wefl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or X)No with 1SA 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 erplain 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-i is needed.Indicate TOTAL NUMBER of wells
drilled:I SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface:445 (ft) 24a.For All Wells: Submit this fonn 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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 00 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.e.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)5 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
13b.Disinfection type:chlorine Amount:22 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