GW1--00363_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO' DESCRIPTION
4449-A 200 ft 210 w 2 GPM
280 325 fw 2 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap llcable)
Rowan Well Drilling FROM To DIAMETER' THICKNESS MATERIAL
0 ft' it 61/4, '°' SDR21 PVC
CompanyCompanyName 23-203 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: MOM TO ; DIAMETER THICKNESS MATERIAL
List all applicable wellconstruclion pennils(i.e.UIG County,State,Variance,eta) ft. ft. l' in.
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3.Well Use(check well use): ft. ft, : In-
Water Supply Well: t 1.SCREEN
FROM TO ' DIAMETER SLOTSIM THICKNESS MATERIAL
Agricultural °Municipal/Public 0 ft: • ft in.!
Geothermal(Heating/Cooling Supply) x°Residential Water Supply(single) ft, ; iL in,
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT i, -
Irrigation MOM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 fe Holeplug Gravity 15 bags
Monitoring °Recovery ft. ft. ,
Injection Well: ft ft.
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Aquifer Recharge °GroundwaterRemediation 19.SAND/GRAVEL PACK(ifapplicable)
_.:Aquifer Storage and Recovery °Salinity Barrier FROM ' TO . MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets ifnecessary)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) -FROM TO 4 DESCRIPTION(color,hardness,aok a&type,grata she,etc.) -
0 it 18 11. Clay
4.Date Well(s)Completed:12C13/23 WellID#23-203 18 f4 35 ft' Weathered Rock
Sa.Well Location: 35 ft. 45; Solid Rock
Chris Smith 90 it 95 it Soft off colored vein _
Facility/Owner Name Facility RV ft. a J:Al
4{9121 Lancaster Hwy, Waxhaw 28173 . ft i ft' "''PhysicalAddtess,City,andZip '• ` 2e
7Z4lD#(i
Union 05 075 004 21.REMARKS . .
' in r/rra:K l tPm,.;� . ing lit iii
County Parcel Identification No,(PIN) 'XX:3:r-G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification:
34 51 .4.827 N 80 42 43.871 W tZi t� 123
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6.Is(are)the we➢(s)JPermanent or °Temporary Si (Certified Well r Date
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By signing this form T hereby certify that the wells)was(wore)constructed in accordance
7.Is this a repair to an existing well: °Yes or %°No with 15A NCAC 02C;0100 or ISA NCAC 02C.0200 Well Construction Standards and that
If this is a repair,fill out known well construction information and etplan the nature of the copy of this record has been provided to Ike well owner.
repair under#21 remarks section or on the back of thisform i
23.Site diagram or additional welidetaits:
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 I is needed. Indicate 1`OTALNUMBER of wells construction details. Yon may also attach additional pages if necessary.
du 1 drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:325 (ft) 24a.For Ail Wells: Submit this foram within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 2®100') construction to the following:
10.Static water level below top of casing:20 (ft.) Division'of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cep ter,Raleigh,NC 27699-1617
11.Borehole diameter:6 (m) 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
II Well construction method: ry construction to the following:
(i.e.auger,missy,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.Yleld(gpm)4 Method of test:weir 24e.For Water Snooty&Infection Wells: In addition to sending the form to
Chlorine 15 oz the address(es) above, also submitl:one copy of this form within 30 days of
13b.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 1 Revised 2-22-2016