GW1--02888_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
Spencer Adams 14:weTERzoNFs... ;
Well Contractor Name FROM TO DESCRIPTION
4449-A 86' n 95 n 4 GPM '
NC Well Contractor CedificationNumber 160 180 4 GPM
• 15:OUTER:CASING(fe maltN Med*vein)ORLINERM. lldabler.' ;
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 178 ft• 1 61/4 in. I SDR21 PVC
OS V Y P2O2322V 77 ..16.INNER CASING OR.TUBING(seetbermel desed�loon) ':
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e UIC,Corny,State,Variance,eta) ft ft. In.
3.Well Use(check well nse): ft. ft. to
Water.Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MAMMAL
°Municipal/Public 0 ft. fa In.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
lndustriaVCommercial ft. In.
Residential Water Supply(shared)
`.Irrigation FROM TO :.MATERIAL• " EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R' 20 ft• HOleplug Gravity 14
Monitoring E3Recovery
Injection Well: ft. ft.
Aquifer Rec ft. R.
age OGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier .FROM
PACK(tfapplleeble) :'
PROM TO MATERIAL EMPLACEMRNTMETHOD
Aquifer Test DStormwater Drainage ft: ft.
Experimental Technology OSubsidence Control ft.
ft. j
Geothermal(Closed Loop) DTracer ::20.DRILLINGLOG(attach additional aieete'if necessary).':.: -
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks FROM TO DESCRIPTION{color,hardness,wntrak twee,agrdn due etc
4/23/24 202322677 ) 0 ft. ZO '� Clay I
4.Date Well(s)Completed: Well IN 20 ft 50 flu. Sandy Overburden
Se.Well Location: • 50 ft' 68 R' Weathered Rock
JIM BELOFSKI . 68 n 78 ft. Solid Rock
Facility/Owner Name Facility ID#(if applicable) 86 ft. 95 R. vein/large chunks
143 Summer Hut Lane, Statesville 28625 160' 180 t• vein/large chunks
Physical Address,City,and Zip ft. ft.
Iredeil 3784 20 7075 :21:REMARKS ::-.: : ,.....: : .::11..:';.....'::-..:::.:-,: ,, ,.
_ , s1;a
County Parcel Identification No.(PIN) " S...,'t L.i b r
Sb.Latitude and longitude in degrees/minutes/seconds ordeefmal degrees: I MAY 1 0 2024
(ifwell field,one lat/long is sufficient) ' 22. cation:
35 45 57.631 N 81 4 54.198 I
6.Is(are)the well(s)D%Permanent or Temporary Sig of Certified Well Contractor Date
By signing this form,I hereby cell&that the sells)war(were)constructed in accordance
7.18 this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis isa repair,Juloutknown well construction information and explain the nature of the copyofthi-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 I GW 1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled t SUBMITTAL INSTRUCI'1ONS
9.Total well depth below land surface:245 (ft.) 24a. For AU Wells: Submit this,form within 30 daysof completion of well
For multiple sells list all depths ifdifferent(example-3®200'and2®100) P
construction to the following:
10.Static water level below top of casing:15 (ft.) Division of Water Resources,Information ProcessingUnit,
If water level ss above casing use"+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter:6 (in.) 24b.For Infection 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 past,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)8 Method of test:weir 24c.for Water Sunnlv Injection Wells: In addition to sending the form to
chlorine 13 02 the addresses) above, also submit 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. •
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-20I6