GW1--01771_Well Construction - GW1_20240320

Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4449-A 430 fL 440 ft• 30 GPM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if op usable)
Rowan Well Drilling FROM TO DIAMETER , THICKNESS MATERIAL
0 ft. 95 ft. 6 1/4" In• sdr21 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
10013640
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft• ft• io.
ft. ft. In.
3.Well Use(check well use):
Water Supply Well: 7.SCREEN
pp y F FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
()Agricultural ()MunicipavPublic 0 ft• ft. In.
OGeothermal(Heating/Cooling Supply) X)Residential Water Supply(single) ft. ft. In.
()Industrial/Commercial ()Residential Water Supply(shared) is.GROUT
()Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Holeplug Gravity 13 bags
Monitoring ()Recovery fL ft.
Injection Well: ft• ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ()Stormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
()Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTIONicolar,hardaess,mil/rock type,grata du,etc.)
()Geothermal(Heating/Cooling Return) nOther(explain under#2I Remarks) 0 R 25 ft• red clay
4.Date Well(s)Completed:2/6/24 Well ID#10013640 25 ft• 70 ft. sandy overburden
5a.Well Location: 70 ft' 85 ft• weathered rock
Aaron Coffey 85 ft. 95 ft• solid black granite
Facility/Owner Name Facility tD#(if applicable) 430 ft• 440 ft. major fracture?-'
4435 Beam Rd, Charlotte 28217 ft. ft. '
Physical Address,City,and Zip ft. ft. _
Mecklenburg 141 301 07 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35 11 6.383 N 80 56 6.181 W � v i._ _7 1.--I 17 LI
6.Is(are)the well(s)OX Permanent or ()Temporary
Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yea or XONo 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:
S.For GeoprobefDPT 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@i00') construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use '4" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For iniection 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:
(i.e.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) 30 Method of test:Weir 24c.For Water SUDDIV&Iniect(on Weill: 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
Amount: 23 OZ completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016