GW1--00320_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATliRZONriR I.
Well Contractor Name
FROM TODESCRIPTION
4449-A 300 ft- 330 ft. 4 GPM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mold-eased wells)OR LINER(if op Usable)
Rowan Well Drilling FROM TO DIAMETER. THICKNESS MATERIAL
Co yNa� 0 ft- 70 ft. 6'U4 1O- SDR21 PVC
2023-39476 16.INNER CASING ORTUBING(geothermal elosed-loop)
2.Well Construction Permit#: FROM TO 4 DIAMETERU T ICKNESS MATERIAL
List all applicable well construction permits(i.e.UJC.County,State,Variance,etc.) ft. R In.
3.Well Use(check well use): ft: 4 ff. , In.
Water Supply Welk 17.SCREEN.
FROM TO ' DIAMETER, SLOT SUE THICKNESS MATERIAL
Agricultural EMunicipal/Public 0 ft. -ft. in:
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft, I ft in:
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO ; MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0 ft• 20f ft- Holeplug Gravity 24 bags
Monitoring ORecoway flu ft;
Injection Well: ft.
Aquifer Recharge DGmundwater Remediation
19..SAND/GRAVELPACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO '. MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. i ft •
Experimental Technology E3Subsidence Control ft. i f7.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#211temarks) PROM TO + DEsCRtrtsox(cota,bmafless,eowroc 47'4 grain'Ile'tic.)
0 t- 20, >z Clay 11
4.Date Wel(s)Completed:)2114123 Well ID#2023-39476 0 fa 60 ft. Sandy Overburden
5a.Well Location: 60 70, ft' Solid;Rock
Northiake Development 70 ft. 110 & Soft Blue Rock
Facility/Owner Name FaciitylD#(ifapplicable) ft' i ft' p ',f' 7 F3 fr..
156 Clear Springs Rd, Mooresville 1 n
Physical Address,City,and Zip ft. ft. JAN Lt ,Z(AZ4
Iredell 4659 06 9373 2LREMARKS .
County Parcel Identification No.(PM) 9nforcer^o;ien Prac'e. U
DWaisOG
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.C rtificatlon; }n
35 38 56.093 N 80 50 53.866 w �i �( (i_� i-I i q 1,23
6.Is(are)the wells) Permanent or QTemporary Signature of Certified Well Contractor Date
By signing this form_I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or xONo with 15A NCAC 02C.0100.or 1SANCAC 02C.0200 Well Construction Standards and that a
"this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been Provided to the well owner.
repair under#2I remarks section or on the back of this fonn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well site details or well
construction,only I GW1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:) SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface:345 (ft-) 24a.For MI Wells: Submit this"form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200`and 2®100) construction to the following. ,
10.'Static water level below top of casing: ( ) Division of Water Resources,Information Processing Unit,
Ifwater level irabove casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 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:
(Le.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of teak Weirchl 24c.For Water Sum&Iv&Injection Wells: In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of
chlorine 16 oz completion of well construction to the countyhealth department of the county
Db.Disinfection type: Amount: mP
where constructed.'
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016