GW1--02469_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ^- s
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
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Well Contractor Name FROM TO ' DESCRIPTION
4449-A 228 rt 240 fr. 4 GPM 1 1
ft. ft. 1 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Rowan Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
0. 25 ft 61/4 la SDR21 PVC
Company Name 405963
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.UIG County,Stag Variance,etc.) ft. ft. , in.
3.Well Use(check well use): ft. ft. I hi.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft ft. In.1
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. In.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
I :Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 st Holeplug Gravity 12 bags
Monitoring - fRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
C Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft ft. i.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO ' DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) 0 17 ft. clay I
4.Date Well(s)Completed:3/12/24 Well m#405963 17 n 25 . solid rock
Se.Well Location: D fr 1 . I. 77 71 t�-, .
Brian Sproul ft ft i v,,,_",:...pi......► ' C:? .
Facility/Owner Name Facility ID#(if applicable) ft. APR 2 2074
390 St Andrews Church Rd, Woodleaf ft. ft. .
ft ft. tnSCi:;�:d;c' i::'',--+^.:Jx,
Physical Address,City,and zip '✓i )
Rowan 809A037 21.REMARKS E• ,.;`,-
County Parcel Identification No.(PIN) 1'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ertifieation:
35 46 43.762 N 80 34 8.141 W r 3
Iz. La it
6.Is(are)the well(s)0 Permanent or Temporary Signature of Certified Well Contractor , 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: DYes or alo with 15A NCAC 02C.0100 or ISA NCAC102C.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#2I 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 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.
filled'1 SUBMITTAL INSTRUCTIONS I'
o
9.Total well depth below land surface:265 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@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 to above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In additi�Ito 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: 1
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm)4 Method of test:weir 24c.For Water Suunhv&Infection Wells: In addition to sending the form to
chlorine 12 OZ the address(es) above, also submit l'one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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