GW1--00039_Well Construction - GW1_20231218

' ( Print.Form:' .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
Spencer Adams 14 WATER ZONES
Well Contractor Name FROM TO DESCRIP'IVON
4449-A 210 to 240 I. 3 GPM '
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING(for multi-caned wells)OR LINER(if ap limbic)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL.
Company Name 0 ft' i 121 s. 161/4 In. I SDR21 PVC
2023-28203 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,eta) ft. ft. In.
3.Well Use(check well use): ft f hi-
Water Supply Well: 17.SCREEN
f.. Agricultural QMunicipal/Public FROM. TO DIAMETER SLOT SIZEI THICKNESSI MATERIAL
Q ft. tZ In.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single)
7ndusttia1/Commercial ft to
Residential Water Supply(shared)
Irrigation IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
son-Water Supply Well: 0 20 Holeplug Gravity 8
Monitoring f Recovery ft. ft.
Injection Well:
Aquifer Recharge QGroundwaterRemtdiiation R' ft'
Aquifer Storage and Recovery OSalinityBauier 19.SAND/GRAVEL PACK(If applicable)
FROM TO I MATERIAL, EMPLACEMENT METHOD
Aquifer Test DStormwaterDlainage ft. tt
Experimental Technology DSttbsidence Control ft.
Geothermal(Closed Loop) QTracer 20.DRI LING LOG(attach add 11onal sheets If necessary)
Geothermal(Heating/CoolingReturn) [ MOther(explain under#21 Remarks) FROM To 9/22/23 DCRIPTION(cold,hardness,sowrecktype,grain size,etc.)
-28203 0 15ft. clayESI
4.Date Well(s)Completed: Well m#2023 15 ft. 90 ft. Sandy overburden
5a.Well Location: 90 ft. 111 sr• weathered gravel
Sanford Yandle 111 tt 121 ft. solid rock
Facility/OwnerName FacilitylDti(if applicable) 210 240 ft' iron rich vein
•1527 Oak Ridge Farm hwy, Mooresville cot ft. ;i -�-
Physical Address,City,and Zip ft. ft. �-.•..' , a -i C
Iredell 4677 89 0855 21.REMARKS ' ,. 0 r- (, I S 20z-3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in.degrees/minutes/seconds or decimal degrees: to"'!"o �� ^t;n �minA
(if well field,one laMoag is sufficient) 22.Certification: Gv`;°',J .'s
35 36 19.254 N 80 45 21.900 W
6.Is(are)the welt(s) ermanent or QTemporary Si fCertified Well Contractor . Date
By signing this form,I hereby cent(that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo with ISA.NCAC 02C.0I00 or ISA NCAC'02C.0200 Well Construction Standards and that a
If this ire repair,fill out Jawwn well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repairunder 112I remarks section or on the back ofthis 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additionalpages if necessary.
drilled 1
345 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdifferent(crimple-3(200'and2Ql00)
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above ding use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
1L Borehole diameter:6 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this�fmm within 30 days of completion of well 12.Well construction method: Rotary
(r e. p construction to the following:
anger,rotary,cable,direct push,etc.) g
FOR WATER SUPPLY WELLS OHI,Y: Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield m 3 weir
(gP ) Method of test: 24c.For Water Sunnis,&Injection Wells: In addition to sending the form to
Chlorine 16 OZ 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016