GW1--02882_Well Construction - GW1_20240510

w,
PrintPorm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES .- '
FROM TO DESCRIPTION
Well Contractor Name 140 ft 170 it. 2 GPM
4449-A 260 ft 280 ft. 6 GPM
NC'Well Contractor CettificationNumber 15.OUTER CASING(far mnit1 cased wells)OR LINER Of ltcable)."
Rowan Well Drilling FROM DIAMETERL THICKNESS MATERIAL
0 • ftJ 88 ft- 61/4 'm• SDR21 PVC
Company Name OSWP202448925 ;166..ISMERCASIN G:ORTOBIN M TO R eriniti THICKNESS ed )::.'
2.Well Construction Permit#:
List all applicable well lconsiruaion pennits(Le.WC County,State,Variance,etc.)
3.Well Use(check.well use):. ft, ft. to
Water SupplyWell: 17:'SCREEN?:..
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
DAgricultural ()Municipai/Public 0 ft. ft. In.
()Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) g. ft In.
()Industrial/Commercial Residential Water Supply(shared) 18?.GRUUT %:'.
firigation FROM TO MATERIAL EMPLACasntarMETHOD&AMOUNT
Non-Water Supply Well: 0 .ft. 20 ft Holeplug Gravity 8 bags
Monitoring E3Recovery ft. ft.
Injection Well: ft ft.
DAquifer.Recharge ()Groundwater Remediation
19:SANDIGRAVEL PACSpf appllcablel
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERiAi: EMPLACEMENT ML+TTRon.
Aquifer Test EDStormwater Drainage 1t ft'
Experimental Technology OSubsideace Control ft. ft
Geothermal(Closed Loop) .Tracer 20 DRILLING LOG(att th 9ddltioiial sheets if neCes ary)..:.
FROM. TO DESCRIPTION(toter,hardness,soli/rocktype,grain etee.etc.)
Geothermal(Heating/Cooling Return) Other(explain under#2l Remarks) 0 ft, 20 ft• CIBy j
4.Date Well(s)Completed.44/17/24 Well IN 202448925 20 ft 50 ft. Sandy'Clay
5a.Well Location: 50 ft' 78 ft' Weathered Rock
Northlake Development 78 R: 88 ft. Solid Rock
Facility/Owner Name FacilitylD#(if applicable) f
1043 Fern Hill Rd, Mooresville 28117 ft ft. i, -...i::.'_; sa.a_.
PhysicatAddress,City,and Zip ft. ft.
iredell 4639 20 8717 .21 REMARi(s: :. MAY.:1..:6 .202..4
County Parcel Identification No.(PIN) I lPw:.;• •• :°. ; .- ',. -. r'Y.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r-4t V`-; i,.'
(if well field,one tat/long is sufficient) 22.Ce cation: 4
35 37 58.634 N 80 54 33.260 W yL4. 10 2.A
6.Is(are)the well(s) Permanent or ()Temporary Signature of Ce ed Well Contractor Date
By signing this fin,1 hereby certlfr that the wwl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or E)No with 15A 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:
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.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a.For All Wells:. Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdlfferent(example-3®200'and 2QI00) construction to the following:
10.Static water level below top of casing: (ft) Diivision of Water Resources,Information Processing Unit,
If water levelly above casing use"+" 1617 Mail 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
Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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)8 Method of test:weir 24c.For Water Supply&Iniecdon 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: 14 OZ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016