GW1--00015_Well Construction - GW1_20231218

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"WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
1.Well Contractor Information: ,
Spencer Adams 14.WATER ZONES.
FROM TO DESCRIPTION
Well Contractor Name
340 ft 405 ft 10 GPM1
4449-A ft ft j
NC'Well Contractor Certification Number 15.OUTER CASING(for multi-cased*ells)OR LINER(If au amble) -
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 44 ft. 6114 ! bi. SDR21 PVC
Company Name
16.INNERCASINGORTUBING(geothermaleloaed-loop)
364108 -
2.WellConstructionPermit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) ft. ft. I. in.
3.Well Use(check well use): ft.
Water 3 Well: 17.SCREEN
Supply FROM TO DIAMETER I SLOT SITE THICKNESS MATERIAL _
AgriculturalIII Municipai/Public 0 ft: ft In.' •
Geothermal(HeatingfCooling Supply) %Residential Water Supply(ogle) ft ft. in.
Industrial/Commercial • QResidential Water Supply(shared)
Irrigation _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - 0 ft 20 4 ft- Holeplug Gravity 7
Monitoring- QRecove1,5 i r rt. ft. I .
Injection Will: ft. ft.
Aquifer Recharge QGmunrivlater Remediation I,
19.SAND/GRAVEL-PACK(If spoilable) -
AquiferStorageandRecovery ElSalinityBarrier • FROM TO MATERIAL EM LACEMENTMETHOD
i Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology QSubsidenceControl ft. ft.
Geothermal(Closed Loop) QTracer .. 20.DRILLING LOG(attaeb addlttonal•sbeets If necessary): .'
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(tutor,hardness aou/ruektsae t atae,etc
0 ft 15 ft. clay 1 '
4.Date Well(s)Completed:9125123 well ID#364108 15 ft. 44 ft solid rock
ft. ft.
5a.Well Location: .
Scott& Kim Meesters ft. "
Facility/Owner Name Facility II)#(if applicable) ft. ft. I. '`:�z y,.,,i.• T• ,.' '',�
155 Cloud Top Lane, Mooresville 28115 ft ft. d'~ C 1 8 NCI
Physical Address,City,and Zip ft. , ft. , .,-;
Rowan 215B057 RI.REMARKS i •—it r- --:.i2 •-• r^
County Parcel ldentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification: '�
35 36 50.355 N 80 44 34.408 W 9 125 123
6.IS(are)the well(s)lX Permanent or QTemporary igmture f Certified 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 EiNo 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 ofthis record has'been provided to the well owner.
repair under#21 remarks section or on the baclkof 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 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.
1,
drilled 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 (ft) 24a.For All Wells: Submit;this form within 30 days of completion of well
For multiple wells list all depths rfdrfferent(example-3@200'and2@l00'. construction to the following: I
r •
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in) 24b.For Infection Wells: Inj 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 27699-1636
13a.Yield(gpm)10 Method of test:air 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
Oh.Disinfection type:
Chlorine Amount: completion OZ c etion of well construction to the county health department of the county
where constructed.
Porn GW-I • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016