GW1--00058_Well Construction - GW1_20231218

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: FiInI Form ::;.
1.Well Contractor Information:
I
Spencer Adams '
I4':WATER'ZONFS'. ;;t
Weli Contractor Name FROM i TO DESCRIPTION
4449-A 200 ft- 300 ft. I '
a GPM
NC Well Contractor Certification Number ft. ft. f
Rowan Well Drilling .iS OUTER'CASI!iG(for;muhrcasedwells)ORLINER(ifap hcabte)•`. ..
FROM TO DIAMETER THICKNESS MATERIAL
.,...
0 ft ft
6
Company Name 16:INhER:C 7ASING ORTUBIN1G(get'r thised-loop)-;: PVC
WELL 05 2023 196904 2.Well Construction Permitff: FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable.well construction permits(i.e.UiC,County.State,Variance,eta) ft. ft. lhi.
3.Well Use(check well use): ft ft in.
Water Supply Well: 1Z`SCREEN •. {3 ,' .
Agricultural FROM TO DIAMETER ISLOTSIM THICKNESS MATERIAL�Municipal/Public ft. fr: m. i,
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
ft. k in. ,
Industrial/Commercial DResidential Water Supply(shared) ;
Irrigation FROM TO MATERIAL I EMPLACEIDEN'r METHOD&AMOUNT
Non-Water Supply Well: o ft. 2D ft.
Holepiug Gravity 8 bags
Monitoring 0Recovery ft. ft.
Injection Well:
Aquifer Recharge OGroundwater Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SANDIGRAVEL PACK(ifaiMlicab)e)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft, ft-
Experimental Technology E3Subsidence Control ft. ft. 1
Geothermal(Closed[pop) Tracer
:20.nRILLING:LOG:(attach'eddirionaieheett,ifneee'ssery) .
Geothermal(Heating/Cooling Return) 'f Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness sodl ock cvae grain else etc.)
o ft 20 ft- Red Clay I
4.Date Well(s)Completed:9/15/23 Well 1D#196904 20 R 63 ft.
Sandy Overburden
5a.Well Location: m ft. 73 ft. Solid Rock
Robert Patton . •ft. ft.
Faci ityJOwner Name Facility ID#(ifapplicable) it. ft. N.c 4.r1+..:..ti :?/ 4 ...-Li
3709 Cheviot Hills Rd,Sherrills Ford 28673 ft. ft.
Physical Address,City,and Zip ft ft. G r C O L
Catawba 4607-2754550 ::21.'REMARKS ;:a,:r�;:Fa,.a ;;r i' ::'. .r
aY:�ti'
County Parcel Identification No.(PiN) I' D " V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one lat/long is sufficient) 22 edification:
_ic:s.........,
35 35 22.616 N 80 59 37.139 w
6.Is(are)the well(s)Jx Permanent or Temporary rgoature o Certified Well Contractor Date
By signing this farm,I hereby certify that the;wells)was(were)constructed in accordance
7.is this a repair to an existing well: DYes or 'rj No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has beenprovlded to the well owner.
repair snider#21 remarks section or on the backofthisfonn.
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 I 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: 325 O 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division ofWater Resourc ,information ProcessingUnit,
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
(ie au er,to construction to the following:
S tary,cable,direct paste,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) Method of test: Weir 24c.For Water Sunnly&infection Weils: hi 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: 15 oZ completion of well construction to the bounty health department of the county
where constructed. {I
Form GW I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016