GW1--02883_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
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1.Well Contractor Information: ,
... . ... ..... . ... . .
Spencer Adams
FROM TO DESCRIPTION
Well Contractor Name 167 170 6 GPM
4449-A ft. ft.
NC Well Contractor Certification Number 15rOUTERCASING:(fol:multl-caled:welli)OR LINER(Hi ble)` .
ROWAN WELL DRILLING FROM TO DIAMETER THICKNESS MATERIAL
0 ft 1164 R. 161/4 ;' I sdr21 IPVC
Company Name OSWP202446909 6.OMNERCt ING;OR.TUU TO DINE hIT ) . ::.THICKNESS MAT.::..:.: :....
2.Well Construction Permit#: ft it. In.List all applicable well construction permits(Le.U1C,County.Stab Variance.etc.) In.
ft. ft.
Well Use(check well use):
Water Supply Weil: FROM TO DIAMETER SLOT SITE IIICttNESS MATERIAL
Agricultural OMuntcipal/Public 0 ft• ft hs.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft, it 1n.
Industrial/Commercial OResidential Water Supply(shared) ;,18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Noonn-Water Supply Well: 0 ft- 20 ft- Holeplug Gravity 25 bags
Monitoring °Recovery ft. ft.
Injection Well: ft fc
Aquifer Recharge OGromdwater ltemediation
Aquifer Storage and Recovery EpSahmty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 't S.
Experimental Technology °Subsidence Control ft ft•
Geothermal(Closed Loop) ()Tracer `20:DRILLINGLOGlittaeh'addidoiuliheettIeecRurt):,;.
FROM TO DESCRIPTION Won hardness,sell/rocktvP4 Rol°ate.ere.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft 20 tt. clay F ,
4.Date Well(s)Completed:4/15/24 Weil,B#oswp202446909 20 ft. 150 't Sandy Overburden
160 n 154• ft' Weathered Rock
5a.Well Location: 154 ft- 164 ' Solid Rock
IQ CUSTOMS ft-
FacititylOwnerName Facility MU(if applicable) 167 't 170 ft* SOFT ZONE f'-': 7—...---:-.:--- '-,-.-
•`e < ... -.. 1,
116 EMMALINE COURT, Troutman 28166 ft ;,,i '`;f i.—,__.fft. ft.
�/��/
Physical Address, MAY City, . I`:.:° %n�}::Ll'L
Iredell 4730 51 3337 2LREI +RKs
County Parcel Identification No.(PIN) `A
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:.(ifwell field,one latfong is sufficient).
35 39 45.108 N 80 54 5.707 W A .________, i 1 5`' 12 4
• Signature of Certified Well Contractor: ; Date
6.Is(are)the well(s)0Permanent or °Temporary 1
By signing this form.I hereby cent frthat the Well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ®No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copyedits record has been provided to the well owner.
If this is arnpoir,j111 out known well construction Information and espial?,the nature of the
repair under MI 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(3W-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additionalpages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS '
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9.Total well depth below land surface:345 (ft) 24a.for All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iif d ferent.(example-3@200'and 21§i00') construction to the following:
10.Static water level below top of casing:20 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
6 In. 24b.For Injection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter: ( )
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.anger,salary,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
6 ,Method of test:weir 24c,For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(Sera) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:chlorine Amount: 16 OZ completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
Fours GW-11
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