GW1--01033_Well Construction - GW1_20240212

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Prlrit Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATERZONES I ' 111
Well Contractor Name PROM TO; DBSCRIP.'TION
4449-A 430 ft- 440 to 17 GPM
,w ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of ap licable)
Rowan Well Drilling FROM TO : - DIAMETER; THICKNESS MATERIAL
Company Name 0 ft' 104 1t 61/41 !°' SDR21 IPVC
391474 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: MOM TO t DIAMETER; THICKNESS MATERIAL
List all applicable well construction permits(Le.VIC County,State,Parlance etc.) ft. ! ft. !: tn.
3.Well Use(check well use): ft. ! ft. i' is
Water Supply Well: 17.SCREEN i I '
FROM TO i DIAMETER I SLOT SITE THICKNESS MATERIAL
Agricultural- QMumcipai/Public 0 ft. i ft. In.:;
Geothermal(Heating/Cooling Supply) k[,Residential Water Supply(single) g ;fL In,; .
Industtial/Commercial 13ResidentiaI Water Supply(shared) 18.GROUT
-- Irrigation FROM TO i - MATERIAL EMPLACEMENT A AMOUNT
Non-Water Supply Well: 0 ft• 20i IL Holeplug Gravity 8 bags
Monitoring ORecovery ft. i ft.
Injection Well:
Aquifer Recharge jjGroundwater Remediation 19.SAND/GRAVEL,PACK(if applicable)
quifer Storage and Recovery Salinity Barrier MOM so : MATERIAL. EMPLACEMENTAMEIBOD
Aquifer Test QStormwater.Drainage f6 I ft. '
Experimental Technology E3Subsidence Control ft. ft. i'
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additionalabeeth tfneaanry)
Geothermal(Heating/Cooling Return) ',Other(explain under#21 Remarks) FROM TO DFscrupTrox tmmr.nw.ae,nutroekesme,Rolm errs etc)
4.Date Well(s)Comnpleted:.1/2124 welim#391474 4 fL 90 ft. Sandy Overburden
So.Well Location: 90 f' 94; Weathered Rock
Nick Hoffman 94 ft. 104 tt Solid Rock _
---- Facr7itylOwaerNaare Facu7Nty]INl(if applicable) .4-Le ( V k�'ln...
9100 IN NC152, Mooresville ft. i ft. �} m
Physical Address,City,and Zip ft ft. �Cu r LOL
Rowan 230A014 21.REMARKS .,
County Parcel Identification No.(PIN) ttl(Uriv:wDOien 1 l� y uA�
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one 1atilong is sufficient) 22.Certification: ; I
35 35 0.027 N 80 44 9.523 W
6.Is(are)the well(s)4}Permanent or ()Temporary Signature o Cf ertified Well Contractor Date
By signing this forma hereby certl/y that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or OX No with I5A NCAC 02C.b100 or ISA NCAC,02C.0200 Well Construction Standards mid that a
If this is a repair,fill out brown well construction infinnation and=plain the nature of the copy of this record hat beenpravtded to the well owner.
repair under 1121 remarks section or on the bac-of:hisform.
23.Site diagram or additional weft details:
8.For GeoprobelDPT 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.
dulled t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:465 ( ) 24a.For All Wells: Submit this days form within 30
For multiple urlis list all depths[(different(example-3 200'and2®100) construction to the following: 1, ys of completion of well
10.Static water level below top of casing:45 (ft.) Dhlsion of Water Resources,Information Processing Unit,
Ifaater level it above caring use"+" 1617;lllall Service Center,Rale
igh,NC 27699-1617
11.Borehole diameter:6 (In.)
246.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit;one copy of this;form within 30 days of completion of well
12.Well construction method: Rotary
(i.e.auger,rotary,cable,direct push,etc.) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,UndergroundProgram Injection Control
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 17 Method of test:weir 24c.For Water Stiyr&&Injection Wells: In addition to sending the form to
Chlorine 21 OZ the address(es)above,also submit lone copy of this form within 30 days of
136.Disinfection type: Amount: completion of welliconstruction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016