GW1--02419_Well Construction - GW1_20240422

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 1�:wATERzolvas; i::
Well Contractor Name FROM TO DESCRIPTION
4449-A 220 ' 280 IL 2 GPM I •
NC Well Contractor Certification Number 425 485 ft. 3 GPM l
S::OUTER CAKING(roR:muttlsaaed wasy.Oft LINER Of lip•llcable) :::
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name .1 .1 0ft 74 6114 ' �' SDR21 PVC
1408 t. 16.1NNERCASINGOR TUBING{Reotheri0alclosed-loop);:::;:..:::.::•::::r::•:: ',.'.:;::::::
2.Well Construction Permit#: FROM - To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance eta) ft ft. • in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER •SLOT SIZE THICKNESS MATERIALD
Agricultural E3Municipa1fPublic N0 ft, ft, In.
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) to
Industrial/Commercial Residential Water Supply(shared) ;18;:GROUT.
Irrigation• FROM TO MATERIAL...... EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: 0 fa 20 ft Holeplug Gravity 8 bags
OMonitoring °Recovery ft ft.
Injection Well:
ruiuer
Recharge Groundwater Remedietion
Aquifer Storage and Recovery
19 SAND/GRAVELPACK(If appacableT
g Very �SalnutyHamer FROM To MATERIAL EMPLACEMENT METHOD
uifer TestStormwater Drainageerimental Technology °Subsidence Control fe ft.othermal(Closed Loop) Tnicet ,..2t1:DRILIUNG LOG(attach'iddlll I sheet,Ifueceuary) • •othermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ' TO DEscmniON(color,budsaq mtWmck evne,grain du,etc)
3/25124 14081 ° ft. 20 ft- clay
4.Date Well(s)Completed: Well ID# 20 R 64 Sandy'Overburden.. -- , , •; ; ,••-•.
5a.Well Location: 64 ft' 74 ft. Solid Rock `', t 4--•' it 1... ..)
Matt Saer ft. ft' AP{' iGZl}
Facility/Owner Name Facility ID#(if applicable) ft. ft.
320 Whippoorwill Lane, Mt Holly 28120 ft ft. " ,:• _,,�,.::-�•
Physical Address,City,and Zip ft. ih tRS: y :"I}'d ko s J b
Gaston
County Parcel IdentificationNo.(PIN)
Sb.Latitude and longitude In degrees/nrinutes/seconds or decimal degrees:
(ifwell field,one la/long is sufficient) 22. ertiflcation:
35 2313.487 N 81 1 20.665 w
3 125 1zLt
6.Is(are)the well(s)0 Permanent or °Temporary signs of Certified Well Contractor 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: DYes or E)No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a 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 021 remark section or on the back of this form.
23.Site diagram Or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 10W-1 is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:t
SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface:485 (R•) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example.3Qa 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level Li above casing,use"+"
1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.)
24b.For Injection 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)5 Method of test:weir 24c.For Water Sunnly&Iniection'Wells: In addition to sending the form to
chlorine 22 Ot • the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to die county health department of the county
where constructed.
Form OW-i North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016