GW1--00064_Well Construction - GW1_20231218

Pinnt f. n:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
Spencer Adams 14.WATERZONES I 1
WellContracioiName FROM TO DESCRIP'ITON
4449-A 65 fw 100 ft• 1 GPM 1
190 ft. 210 ft• 25 GPM I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(If ap Itcable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 58 61/4 !'ta, SDR21 PVC
2.Well Construction Permit#: DIAMETER CHA-WE-2022-00009 16Q�ERC SINGORTOBIN (geothermaldosed-loop)
MATERIAL
List all applicable well construction permits(1e:UIC,County,State,Variance,eta) it. ft. '`In.
3.Well Use(check well use): ft• ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL-
-Agricultural LJMtmicipal/Pubhc 0 ft, ft. in.
R Geothermal(Heating/Cooling Supply) x[ Residential Water Supply(single) ft ft. In.
R Industrial/Commercial °Residential Water Supply(shared) '
IL GROUT
Irrigation FROM TO MATERIAL EMPLACE.'1fENT METHOD&AMOUNT
Non-Water Supply Well: 0 fe 20 ft. Holeplug Gravity 7
IN Monitoring °Recovery H. ft.
Injection Weil:
ft. ft.
N Aquifer Recharge °Groundwater Remediation I9.SAND/GRAVEL PACK(If applicable)
II Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
II Aquifer Test DStormwater Drainage ft ft- P
IN Experimental Technology E3Subsidence Control ft. ft. ''
IN Geothermal(Closed Loop) °Tracer _ 20.DRILLING LOG(attach additional sheets ifneceasary)
Al Geothermal(Heating/Cooling Return) Other(explain-under#21 Remarks) FROM TO DESCRIPTION trier,hardness eoRtroet tuna glen me,etc.)
f"
0 n 20 ft. clay
4.Date Well(s)Completed:9/20/23 Well ID#00009 20 ft. 48 ft* weathered rock
5a.Weil Location: 48 ft' 58 ft' solid rock
JCCH 65 100 various veins brown rock
Facility/Owner Name .FacilityID#.(ifapplicable) ft' ft.
9604 Regent Dr, Davidson 28036 H. ft. .' i—h,_ - 5..-,.
R. --.:.-',,,•'L,.�,i`� 1,,,,./
Physical Address,City,and Zip
Cabarrus 21.REMARKS 0 r.I 1 d zo2 3
County Parcel IdeatificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ""
(if well field,one lat/tong is sufficient) 22.C cation: /14.c.........._„, OW k.A'
43
35 29 26.698 N 80 44.23.743 W 1 lad )23
6.Is(are)the wells) Pernmanent or Temporary Signature o Certified Well Contractor Date
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: Oyes or Olsio 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 captain the nature of the copy of this record has been provided to the'lnsllowner.
repair under ti21 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 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:225 (It.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijterent(example-3th1200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,we"+" 1617 Matz Service Center,Raleigh,NC 276994617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In additi{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:
(ie.auger,rotary,cable,duectpush,etc.) I ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I ,
Method of test:weir 24c.For Water Supply&Injection'Wells: In addition to sending the form to
13a.Yield(gum)25
the address(es) above, also submit one copy of this form within 30 days of
13b.Distnfection type:chlorine Amount 12 OZ 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