GW1--01030_Well Construction - GW1_20240212

Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1
1.Well Contractor Information:
Spencer Adams '14.WATE_ ZONES f R .,
FROM TO DESCRIPTION
Well Contractor Name 195 ft 225 3 GPM
4449-A 240 ft 250 ft 2 GPM
NC Well Contractor Certification Number -
15.OUTER CASING(for mufti-cased wells)OR LINER(if ap likable)
Rowan Well Drilling FROM TO DIAMETER 1 THICKNESS MATERIAL
0 ft 83 ft 61/4 is SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) .. ' •
392496 -
2.Well Construction Permit#: FROM TO DIAMETER • THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State;Variance,etc.) ft ft. , in.
3.Well Use(check well use): Ill•
Water Supply Welk 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
IN Agricultural EjMunicipalfPublic 0 ft ft in.
$Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft ft. in.
ji Industrial/Commercial EiResidential Water Supply(shared) 18.GROUT .
Irrigation FROM TO MATERIAL ,EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fti 20 ft Holeplug Gravity 7
Ng Monitoring nRecovery ft. it.
Injection Well: ft. ft.
11 Aquifer RechargeGrotmdwater Remediation 19.SAND/GRAVEL PACK(If applicable)
II Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
If Aquifer Test DStomtwater Drainage ft ft j
IN Experimental Technology 0Subsidence Control ft
iill Geothermal(Closed Loop) jTracer 20.DRILLING LOG(attach additional sheets If necessary)
1 Geothermal(Heating/Cooling Return) ',Other(explain under#21 Remains) FROM TO DESCRIPTION(color hardness,soNrocktype,groin size,etc)
0 f. 12 ft Clay
4.Date Well(s)Completed:1/29/24 Well ID#392496 12 ft 30 ft- Sandy;clay
5a.Well Location: 30 ft 45 ft- Sandy',overburden
Sean Gibbons 45 ft 73 weathered rock ( E C ir?'�, /L
Facility/Owner Name FaciliityID#(if applicable) 73 ft 83 ft solid rock �r
625 Parks Rd, Woodleaf 83 ft. 95 soft gray rock F tb 1 2 20?4
Physical Address,City,and Zip ft ft.
Rowan 818 032 21.REMARKS tart sr.: it a;;:,;., ,,.s;,,ffi C4
County Parcel Identification No.(PIN)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
35 45 19.652 N 80 35 21.985 W l I,z t )29
6.Is(are)the well(s)1)Permanent or OTemporary Si of Certified Well Contractor I Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or XONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is o repair,fill out brown 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. I,
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:265 (ff.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(exairrple-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(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)5 Method of test:Weir 24c.For Water Supply&IniectionVeils: 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 12 oz
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