GW1--00063_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Spencer Adams la WATER ZONES . .I
Well Contractor Name FROM TO DESCRIPTION
4449-A 164 ft205 ft. Zee++ I I
345 ft. 365 ft' Z GPM 1 1
NC Well Contractor Certification Number ::15i'O11TEItCASING(for mull[-eased hells)OIELiNER(if a' cable) -:-
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL '
0 it 164 ft. 6 114 I ,1n' Sd21 PVC
Company Name l INNER CASING-OR'.TUBING::(Reotbermaltlased loop)_ `
2.Well Construction Permit#:899 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'0.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check Well use): n • fr. to.
17SCREEN;;a::•.:;.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public it, in.
rt. in.
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) it
Industrial/Commercial Residential Water Supply(shared)
d`18sGROUT.
:Irrigation _ - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2D fG HoleptiD Gravity I0 bags
Monitoring oRecoveiy ft. ft.
Injection Well:
ft. ft.
°Aquifer Recharge °Groundwater Remediation
19.SANDIGRAVELPACK'(IfaPPliceble) '' ' '''
E3Aquifer Storage and Recovery E3SalinityBonier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test oStornwater Drainage ft. ft.
°Experimental Technology EDSubsidence Control ft. ft.
°Geothermal(Closed Loop) Tracer -2osDRIL1 INGi oG(lithe'fteddRlouslaheetsirniieasecy} ? :-'s '
Geothermal(Closed/ ooling Return) °Other(explain under#21 Remarks) FROM 7O DESCRIPTION(color,hardness soiur ocktyoe wain sac cued
o ft. 30 ft. Clay I I
9/13/23 899 it. fc
4.Date Well(s)Completed: Well ID# 3D 1aD Sandy Overburden
5a.Well Location: so ft' 154 fr' Weathered Rock
Timothy Harder 154 ft 164 ft Sold Rock
Facility/Owned Name Facility IDA(if applicable) 184 ft rey ft" Softer pink Rock!Brittle
7280 J Warren Lane, Lenoir '- rt. k' ?-i y':u; Y;G—i;,Th
Physical Address,City,and Zip ft; ft.
Caldwell 2875455141 21'REMARlts< ': -. f'i 1 I :.2O 3 -`
CountyParcel Identification No.(PIN)
Irii.—.-wm&.'^.7 r'r; 1-0 r y
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'.:`: ":::,J.,;
Of well field,one tat/long is sufficient) 221: 1ll.
ertification:
36 4 31.286 N 81 27 16.616 W — I l3 123
6.Is(are)the well(s)Jx Permanent or Temporary SignatureCertified Well Contractor Date
.
By signing this fe m.I hereby serf fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or XINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature oldiecopy of this record has been provided to the well msner
repair under ii21 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-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: 385 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifJerent(example-3@200'and 2(100) construction to the following:'
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
II-water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter. 6 (hi) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Seri Service Center,Raleigh,NC 27699-1636
13a.Yield(pm)4 Method of test Weir 24c.For Water Supply&Iniection Wells: 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: 18°Z completion of well construction to the county health department of tite county
where constructed.
Fonts GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016