GW1--00352_Well Construction - GW1_20240112

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PrintForm:
WELL CONSTRUCTION RECORD(GW--1) For Internal Usg Only:
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1.Well Contractor Information:
Spencer Adams 14.WATER ZONES I
Welt.Contractor Name FROM TO DFSCRIPIION
4449-A 112 565 1/2 GPM
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Stable)Rowan well Drilling M TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft 112 f 61/4 n Sdr21 PVC
399985 16.INNEItCASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO i DIAMETER' THICKNESS MATERIAL
List ail applicable well construction permits(le.UIC County;State,Variance eta) ft i6 in.
3.Well Use(check well use): ft ft. ii.
Water Supply Well: 17.SCREEN ?
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultuml QMunicipal/Public 0 ft ft in. ; .
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft in.
lndusttial/Commercial jResidential Water Supply(shared) la GROUT I
Irrigation FROM TO t MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- Holeplug Gravity 14 bags
Monitoring QRecovery ft. ft.
Injection Well: ( 6 f
°Aqu►fer Recharge j jGroundwater Remediation 19.SAND/GRavEUPACIC Of applicable)
()Aquifer Storage and Recovery EjSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
()Aquifer Test QStormwater Drainage ft. i ft.
Experimental Technology ()Subsidence Control ft. ft. i'
QGeothennal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
',Geothermal(Heating/Cooling Return) ("Other(explain under#21 Remarks) ,FROM TO = DESCRIrr19N(colon hardness,self/reek type,mkt dm,etc.)
0 ft- 20 ; ft- Red Clay
4.Date Well(s)Completed:12/19/23 Well ID#399985 20 ft- 100; n. Sandy Overburden
sa.WellLocaaon: ia0 102 ft. Weathered Rock �� r. j �
Jason Allen 102 m 112 ft Solid Rock. i` t""
Facility/Owner Name Facility IDN(if applicable) 119 ft 121 I D- Brown vein `BAN I Z 20.4
11675 NC 801, Mt Ulla ft. ft.
1t. • ft !itf:,r-ccct: .-,:,cr r Ui
Physical Address,City,and Tap C31"vO m1c
Rowan 557 015 21.REMARKS
County Parcel Identification No.(PRO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0 I
(if well field,one lat/long is sufficient) 22.Certification: � � I
35 40 31.838 N 80 41 38.733 w --
it ( iei I23
6.Is(are)the well(s)JX Permanent or Temporary Signature o ertifiedWell Contractor I Date
$p signing this form,thereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or DX No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stmedards and that a
If this is a repair,fill out!mown well canstntcion.Infonnation and explain the nature of the copy of this record has been provided to the Well owner.
repair under#21 remarks section or on the back of thisform 23.Site diagram or additional well details:
6.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:565 (ft-) 24a.For All Well.: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdffereu(example-3@,200'and 2Qa I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!floater level is above casin&use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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1L Borehole diameter:6 (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(he.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) 1/2 Method of test:Weir 24e.For Water Supply&Infection 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: 1-6 lbs completion of well construction to the county health department of the county
where constructed. 1
Fern GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016