GW1--00050_Well Construction - GW1_20231218

Prim form A
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
I
1.Weil Contractor Information:
Spencer Adams t4..WATERZONES !'.:
Well Contractor Name FROM TO DESCRIPTION
1
4449=A 66 ft 100 ft �t,wge 1 ,.
250 ft 270 ft' e GPM i Wye rnke.e
NC Well Contractor Certification Number
I&-OI)1ZR G4SIN0(Cor.'muitrcased tGe1LsTOR GINER'(tf ap cable) .';
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 68 ft 61/4 II in' SDR21 PVC
Company Name
13688 ::16.INNERCASThiaORTUBING(t eothermalehisea loon)..T. -
2.Well Construction Permit#: FROM TO DIAMETER -THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft ft :, ht.
3.Well Use(check welt use): • ft. ft. i; .a.
17.'.5CREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturaL DMunicipal/Public fr. ft. in.
Geothermal(Heating/Cooling Supply) :x Residential Water Supply(single) ft ft. in.,
Industrial/Commercial °Residential Water Supply(shared)
48:GROUT _:.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft.- -Holeplug _Gravity.29 hags
Monitoring E3Recovery ft. ft.
Injection Well: fr. fr.
Aquifer Recharge °Groundwater Remediation lq.'SAND/GrtAVEL PACK(if appL'caLle).
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft R. I
Experimental Technology °Subsidence Control ft. ft. I,
Geothermal(Closed Loop) E3Tracer 2o::DRILLINGLUOtattaivactdltionatsireetsit'necifinie)- '`
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness so0hnektyper grain size,etc.)
0 ft 15 ft. Clay I I '�": 7. "
9/18/23 13688 rt tt I v' —r, ‘1,/ _�
• 4.Date Well(s)Completed: Well Il?# 15 2s Sandy overburden .
Sa.Well Location: „ ft 58 ft alines layers rock l dirt D F'(, 1 y 202 1
)
�Cornerstone 3 Properties- sa 6a ft• solid rock -
Facility/Owner Name Facility1D# a applicable) 74 ft- ea ft ccr..+a•r z t!NS, ,^YR }l Eji{ •
ty (ifpP } brown rode vein t c r<.i..:,:�
148 Watergate Dr,Alexis 28006 80 f` 165 ft various brown rock vein
Physical Address,City,and Zip ft. ft '
Gaston 3670 48 4868 zi:xEitirnwcs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufllcient) 22. ertifieation:
352347:716 N 81 558.153 W •
4) 12,3
6.Is(are)the well(s)f Permanent or °Temporary S"g store Certified Well Contractor Date
By signing this form,I hereby certify thal'ihe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or x3No with l5A NCAC 02C.0100 or ISA NCAC IO2C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction h formation and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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-I 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: 2$5 ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@i00) construction to the following:
10.Static water level below top of casing: 17 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC.27699-1617
I'
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary ' • above,also submit one copy of this ifoim within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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
I.'13a.Yield(gpm) 10 Method of test:Weir 24c.For Water Sunnis,&Iniectioi Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
-13i.'Disinfection type: Chlorine Amount:'14°Z completion of well construction to thel county health department-of the county
where constructed.
Loon GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016