GW1--00041_Well Construction - GW1_20231218

I P i t Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: °
1.Well Contractor Information:
Spencer Adams
Well Contractor Name FROM TO DESCRIPTION
4449-A 320 ft. 360 ft. 4 cru I !
ft. ft. ! .
NC Well Contractor Certification Number
•,15:OUTERCASING'(to-r.'muttreased'iweils)OR LINER''(ifap placable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 85 ft. 8114 in' SDR21 PVC
Company Name
2023-35253 INNER.CASING OR:TU131NG(geotheinial closed-loop)
2.Well Construction Permit•#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc) ft. ft. in.
3.Well Use(check welt use): ft. ft I. in.
Water Supply Well: 17 SCREEN;.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public it ft ;in.
Geothermal(Heating/Cooling Supply) x3Residential Water Supply(single) ft. ft. is
IndustriaUCommercial °Residential Water Supply(shared) Iti:.GROiTI
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20
Hoteplu0 Gravity 8 bags
Monitoring °Recovery ft. ft.
Injection Well: .
ft. ft.
Aquifer Recharge OGrotmdwater Remediation
49.:SAND/GRAVEL PACK(If applicable)
Aquifer Storage and.Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft ft. h
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer _20.•DRI1LIING:LOG.(attsthadditiinalebeetiifnec sicry) -,-;!'-'*,7.'''.; ::
Geothermal(Heating/CoolingFROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Return) Other(explain under#21 Remarks) 0 ft 20 tt Clay
4.Date Well(s)Completed:9/8/23 Well ID#2023-35253 20 ft. 50 ft Sandy obarburden
5a.Well Location: 5 e' 75 ft' weathered Rock
IQ Customs 75 it es R Solid Rock
ft. ft. ' 't L.t t'.. , 'i.
Facility/Owner Name Facility IDll(ifapplicable) .,,:�,j, r`, a.i 9 .I 1
555 Pisgah Ridge Circle, Hiddenite 28636 ft. ft. rti �� p[�� 7
Physical Address,City,and Zip ft. ft. t?rl(
Iredell 4719 36 5846 '2k,REMARKS::' - MCI,.;r f r ,,:- r r .
. d r� t.,tr.i
County Parcel Identification No.(PIN) I C:J`.: i-,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lallong is sufficient) 22.Certification: t .Q____,
J��35 55 26.535 N 80 58 59.433 �,
6.Is(are)the well(s)>Jx Permanent or oTemporary Signs ofCertified Well Contractor! Date
By signing this form,I hereby certity that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or xNo 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 of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this forth.
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.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2 a 100' construction to the following:
10.Static water level below top of casing: (it) Division of Water Re Iurces,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Injection 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,IUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test:weir 24e.For Water Supply&Injection Welts: 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: 20 Os completion of well construction to the county health department of the county
i where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22 2016