GW1--02445_Well Construction - GW1_20240423

Print Form 1
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449—A 240 ft. ;285 h- 10 GPM 1
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Rowan Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft' 96 ft. 6 1/4 to sdr21 pvc
10014351 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.IJIC,County,State,Variance,etc.) ft ft. In.
3.Well Use(check well use): ft. ft. is
SEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) 3Residential Water Supply(single) ft. ft ' in.
Industrial/Commercial IiResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fti 20 ft holeplug gravity 24 bags
Monitoring IiRecovery ft ft.
Injection Well: ft ft.
Aquifer Recharge OGroundwater Remediation I
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Bather FROM TO MATERIALS EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. 1
Experimental Technology DSubsidence Control ft. ft.
i
Geothermal(Closed Loop) DTmcer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,eolllrocktype(vain etc.)
0 ft ft clay
4.Date Well(s)Completed:3/17/24 Well ID#10014351 5 ft 70 ir• sandy overburden _
5a.Well Location: 70 n 86 ft' weathered rock i;--,, i,_.r 2 �V r:,
Anthony Mendez 86 f. 96 solid rock r❑ 2 (jam
Facility/Owner Name Facility RI#(if applicable) ft. ft f�f i� �. t"t—
4220 Irish Lane, Charlotte 28214 ft. ft. ,,, p r --3 Uthi
Physical Address,City,and Zip ft ft L��`"'OC
Mecklenburg 113 161 35 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertification:
35 12 58.624 N 80 58 20.362 W /-,-...___-- 4---A---
31 I - )2 4-
6.Is(are)the well(s)JX Permanent or Temporary Signature of Certified Well Contractor Date
I
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: DYes or ONo with ISANCAC 02C.0100 or 1SANCAC102C.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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page{o 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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and 2 a@100) construction to the following: i
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 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:
(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
I
13a.Yield(gpm) 10 Method of test:weir 24c.For Water Supply&Iniection Wells: 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: 13 OZ 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