GW1--00040_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW--1) For Internal Use Only: I
1.Well Contractor Information:
Spencer Adams 114.WATER ZONES I I
Well ContractorName FROM TO. DESCRIPTION
4449-A 113 ft. 200 ft_ 1.5 GPM
ft. ft. I
NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)OR LINER(If au ileable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 113 6 1/4 SDR21 PVC
2023-349'I 8 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC Corny,State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SHE THICKNESS MATERIAL
Agricultural DMunicipavPubllc 0 fL ft. in.
Geothermal(lleating/Cooling Supply) E Residential Water Supply(single) ft. ft. to.
Industrial/Commercial [Residential Water Supply(shared) is.mom.
f Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: .0 ft 20 Ic Holeplug Gravity
Monitoring QRecovery ft. ft.
Injection Well:
Aquifer Rerharge DGroundwaterRemediation ft fi.
19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwaterDlainage ft. ft. I'
Experimental Technology QSubsidence Control ft. ft. I :
3Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ("Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bantam,wti#roelrtspq groan size,etc.)
0 ft- 18 ft. clay I j
4.Date Well(s)Completed:9/21/23 WellID#34918 18 ft. 100 ft sandy overburden
So.Well Location: 100 113 Solid rock
Richie Stone 122 fr- 128 fe• fracture . -- ' ---, G
ft, ft. • ''.� i;.,,P _.i; 7'o r,:
Facility/Owner Name Facility ID#(if applicable)
284 Alexander Acres Rd, Mooresville 28115 ,t tt, Dr(. 1 8 202 3
Physical Address,City,and Zip ft f3-
Iredell 4677 34 4218 21.REMARKS ,,,;;,,,;.::%w;,,-T:,.,.:cry.Art t,..�y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 35 22.678 N 80 46 15.828 W g I s l i 2%3
Is(are)the well(s)1x Permanent or Temporary Signature bf Certified Well Contractor Date
6.
Q 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: Dyes or x)No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction Information and explain the nature of the copy ofthIs record has been provided to the well owner.
repair under#2l remarks section or on the bock of thisforns 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a.For All Wells: Submit this;fort within 30 days of completion of well
For multiple wells list all depths if different(example-3 e@200'and2Ql0tY) 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
V
11.Borehole diameter:6 (in) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,directpnsb,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)2 Method of test:Weir 24e.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 17 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