GW1--04333_Well Construction - GW1_20240722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: _
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 97 ft. 285 ft• 1/2 GPM_
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased w ells OR LINER if ap Dcable
Rowan Well Drilling FROM To DIAMETER_ THICKNESS MATERIAL.
0 ft 97 ft- 6114 In. SDR21 PVC
Company Name
OSW P 2024 50056 16.INNER CASING OR TUBING(geothermal closed-1
2.Well Construction Permit#• FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: _
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL.
Agricultural ❑Municipal/Public 0 ft. M in.
Geothermal(Heating/Cooling Supply) X)Residential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrrl ation FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. holeplug_ gravity 7 bags
Monitoring DRecovery ft. ft.
Injection Well: -
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifs licabl.e)-
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL_ EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION eobr hardness soll/mIc rain etc.
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) 0 fL 20 f• clay
4.Date well(s)Competed:5/9/24 well Iv#202450056 20 ft. 70 ft. sandy overburden
5a.Well Location: 70 It. 87 ft- weathered rock
Grady Winford 87 ft- 97 ft. solid rock
Facility/Owner Name Facility ID#(if applicable) ft. ft. p l%-
170 Winford Rd, Troutman 28166 ft ft•
Physical Address,City,and Zip ft. it.
Iredell 4750 96 2359 21.REMARKS - j ;°
County Parcel Identification No.(PN _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.7ation:
35 40 38.411 N 80 49 14.594 W
z -
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: [3Yes or X)No with 15A NCAC 01C.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 I 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: 405 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: UL) 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 Injection 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:
(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) 1/2 Method of test:weir 24c.For Water Supply&Infection 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:chloride Amount: 18.5 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