GW1--00360_Well Construction - GW1_20240112

1.--- Print form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name 205 405 1/2 GPM I
4449-A ft. ft. I
NC Well Contractor Certification Number -15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 . 24 ft 61/4 I in. SDR21 PVC
Company Name -16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:23-350 FROM TO DIAMETER - THICKNESS MATERIAL,
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft R I in.
ft3.Well Use(check well use): I in'
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft ft in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) R ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT . . . .
-._ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fa 20 ft Holeplug Gravity 12 bags
Monitoring Recovery ft ft
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)'
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStomtwater Drainage R ft. ,
Experimental Technology 0Subsidence Control ft R
Geothermal(Closed Loop) DTracer -20.DRILLING LOG(attach additional sheets if necessary) ' .
FROM TO DESCRIPTION(color,hardness,soil/rocktype,train size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 205 405 Granite
ft. ft.
4.Date Weil 12/6/23(s)Completed: Well ID#23-350
5a.Well Location: ft I i- k r f c,--.01
Joseph Blocksom ft. , ,, ��++-.q. t t" it—e''r
Facility/Owner Name - Facility 1D#(if applicable) ft. ft Jk"1 1 4 2024
5914 Will Plyler Rd, Waxhaw 28173 - ft ft.
Physical Address,City,and Zip ft. ft
Union 06 072 012A 21.REMARK - , , - -
County Parcel IdentifieationNo.(PIN) Existing well 205'24'casing,20'static,drilled to 405'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1/2 GPM
(if well field,one lat/long is sufficient) 22.Certification:
34 59 16.342 N 804236.014 W , t21 i -
6.Is(are)the well(s)j Permanent or Temporary Signature o Certified Well Contractor I 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: I2 Yes or DNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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 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 t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:405 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'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,use"+" 1617 Mail Service Ce Iter,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: j
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test weir 24c.For Water SUDDIV&Injection Wells: In addition to sending the form to
chlorine 19 oz the address(es) above, also submit one copy of this form within 30 days of
136.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