GW1--00353_Well Construction - GW1_20240112

I Print Form .
WELL CONSTRUCTION RECORD(GW-1) For Internal U$e Only:
1.Well Contractor Information: I
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO i DESCRIPTION
4449-A 270 ft 300 ft' 5 GPM
NC Well Contractor Certification Number 1 h'
1S.OUTER CASING(for multi-cased wells)OR LINER Of so Heable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL Name 0 ft*
Company fe• 61/4 in- r SDR21 lPVC
402982 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO 1 DIAMETER THICKNESS -MATERIAL
List all applicable hell construction permits(i.e.U1C,County,State,Variance,eta.) ft. I ft. 'In.
3.Well Use(check well use): ft. I. R. in.
Water Supply Well: 17.SCREEN
i
Agricultural FROM TO I DIAMETER :SLOT SIRE THICKNESS MATERIAL
!ri DMunioipal/Pablie 0 ft i ft. io.
Geothermal(Heating/Cooling Supply) XDResidentia1 Water Supply(single) ft i B. in.
Indushial/Commerciai DResidential Water Supply(shared)
I8.GROUT l
Irrigation FROM TO : MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n 20 B. Holeplug Gravity 8 bags
Monitoring }Recovery ft
Injection Well: ft.
ft
Aquifer Recharge DGroundwaterRemediation R'
Aquifer Storage and Recovery DSalinityBarrier FRO i PACK Of e) -
EINPLACEMENrMETBOD
Aquifer Test DStormwater Drainage ft. ; ft.
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) DTracer 20.DRILLING Lop(attach additional.sheets Ifneeeame y)
Geothermal(Heating/Cooling Return) ("Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,wtur«rstsnw groinate l
12/29/23 402982 ° f` 20 Clay j
4.Date Well(s)Completed: Well ID# 20 ff. 104 ff' Sandy Overburden
Sa.Well Location: 104 it: 114' 8. Solid ROCk
Ricky Stenhouse 114 t 135? pL Soft rock/flakey
Facility/OsvnerName Facility ID#(ifapplicable) ft. ill ,— T, �..••.D
9280 W NC 152, Mooresville 28115 ; f 1 era. .a ::�_:'
Physical Address,City,and Zip ft I ft. t A N 1 1 2 Z02A
E.Rowan 402982 21.REMARKS : IV `t
Comity Parcel Identification No.(PR) In..7:7r p nr T 2, 171�i'+'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I RWJGY` W
(if well field,one lat/longis sufficient) 22.Certification:
35 35 5.399 N 80 44 27.535 W
,k_s____IL__
t2 (7 )23
6.Is(are)the well(s),x Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this form I hereby cerit&that the well(s)nut(here)constructed in accordance
7.Is this a repair to an existing well: DYes or 1.No with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this its repair,jruout brown well construction information and explain the nature of the
copy ofthis record has been provided to the hell owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I OW-1 is needed.Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:l
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft) 24a.For All Wells:: Submit this form within 30 days of completion of well
For multiple wells list all depths rfd fferent(example-3 200'and 2(g100) construction to the following
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
gassier level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In additionito 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: I
(ie.auger,rotary,cable,direct pushy etc.)
Division of Watei Resources,Underground Injection.Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
{
13a.Yield(gpm)5 Method of test:Weir 24e.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 14 oz the address(es) above,also submit Brie copy of this form within 30 days of
I3b.Disinfection type: Amount: 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