GW1--08045_Well Construction - GW1_20231214

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information
Spencer Adams 14.WATKR ZONES
Welt Contrector Name PROM TO DESCnIFIiON
4449-A 290 ft 320 ft- 9 GPM
it ft. I -
NC Wetl Contractor Certification Number
IS.OUTER CASING(for multten'sed welts)OR LINER(If up noble)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft98. 6144' '°' SDR21 PVC
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#:NA FROM To. DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r e.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 SITE THICKNESS MATERIAL
l Agricultural QMunicipal/Public 0 ft _ ft. In.
I Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single)
ft. FL in.
•Industrial/Commercial ['Residential Water Supply(shared) 18.GROUT
x Irrigation FROM TEC MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 Holeplug Gravity 12 bags
I Monitoring Recovery ft, ft.
Injection Well:
illAquifer Recharge DGroundwater Reniediation ft.
f
all •quiferStorage and Recovery QSalinityBarrier FROMSAND/TO PACK MATERIAL EMPLACEMENT METHOD
III Aquifer Test jStormwater Drainage ft ft. i
III Experimental Technology ['Subsidence Control ft. _ ft. I' '
I Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional Sheets If necessary)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,eoWroektrpe grata she,era)
0 ft- 20 ft Clay,
4.Date Well(s)Completed:11/10/23 Well ID#NA 20 ft 88 Sandy Overburden
Sa.Well Location: es ft 98 1t Solid Rock
Tim Steinman 98 1t 210 1t: Soft/Briddle Rock `" `"• T l k r I i-
Facility/Owner Name Facility DM(if applicable) ft. ' r i
0 Ridenhour Rd, Mocksville ft
Physical Address,City,and Zip ft • ft. s�
Davie 21.REMARICS .Mr.:,:,•. ... ::a:ry. ^p:s3Lm;.s
43
County Parcel IdentificationNo.(PIN) L''`=v 4;"S:r
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
`
(dwell field,one latllongis sufficient) 22.Certification:
35 4718.583 N 80 29 0.332 W
...- 4...-,L,'
1 ► Ito �3
6.Is(are)the well(s)1. Permanent or Temporary Signature of Certified Well Contractor ! Date
By signing this form,I hereby certify that the wells)was(nave)constructed in accordance
7.Is this a repair to an existing well: Oyes or %ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fall out brown well construction infor/nationand explain the nature of the copy ofthis record has been provided to the well owner.
repair under tt21 remarks section or on the back of this fawn 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 OW-I is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 625 (ft) 24a.For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdlfferent(example-3@200'and 2(g100) construction to the following:
10.Static water level below top of casing: (1l:) Division of Water Resources,Information Processing Unit,
Ifwnterlevel is above rasing use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
itBorehole diameter:6 (in.) 24b.For Injection Wells: In addition to sending the them to the address in 24a
12.Well construction method: Rotary flueabove,also submit one copy of ie form within 30 days of completion of well
(i.e.ange,rotary,cable,direct push,etc.) coastmctioa bothe-following. 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ralei
gh,NC 27699-1636
13a.Yield(gpm)9 Method of test:Weir 24c.For Water Snooty Sr Injection Wells: In addition to sending the form to
chlorine 1.80 lb the address(es) above, also submit one 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.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016