GW1--04334_Well Construction - GW1_20240722

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER AMES
FROM t
DSSCRWell Contractor Name
4449-A300 4 GPM
350 IL 360 ft- 3 GPM
NC Well Contractor Certification Number 15.OUTER CASING for maitf<aaed�rdls OR LINER Ilcable
Rowan Well Drilling PROM TO DIAMETER TIDCIavEss MATMULALL
0 & 1134 ft 61/4 1 SDR21 PVC
Company Name
JMB35B6 2024 49256 FRO„�RCTO fL UBI�ET errnal�oCKNM �,�AL
2.Well Construction Permit#: �
List all applicable iwil construction permits(i.e.UiC,County,State,Variance,ek.) ft. ft.
3.Well Use(check well use): ft
Water Su 17.SCREEN
Pl?iY Well: FROM TO In.
SIArf SIZE TIDCIGYGSS MATERIAI,
Agricultural [3Municipal/Public 0 ft. fL In
Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) pt m In.
indush ial/Commercial ©Residential Water Supply(shared) 18.GROU7
Irrl ation FROM TO MATERUL EMPLACEMWfT M[M0D&AMOUNT
Non-Water Supply Well: o ft- 134 ft. EZ Seal Pump 14
Monitoring ORecovery ft. ft.
Injection Well: & ft,
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK applicable
Aquifer Storage and Recovery QSalinity Barrier FROM I TO MATERIAL YMPLACEMLNT METHOD
Aquifer Test QStormwater Drainage ft. ft
Experimental Technology Subsidence Control r ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sherts If necessary)
Geothermal (Heating/Cooling Return Other(explain tinder#21 Remarks mom TO DESCRIM014 I eobr,hardans,aawro* dzg6«e.
0 fL 20 ft- Red Clay
a.Date Well(s)Completed:6/24/2024 Weft ID# 49256 20 ft- 90 fL Sandy Overburden
5a.Well Location: so ft• 129 fL Weathered Rock
Eva Harris 129 fL 134 & Solid Rock
Facility/Owner Name Facility ID#(if applicable) ft. ft.
158 Malibu Rd, Mooresville 28117 ft. ft.
Physical Address,City,and Zip ft
Iredell 4646 22 2452
21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutealseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C rtiHeadon:
35 33 19.639 N 80 52 31.221 W �, d iz4
6.Is(are)the well(s)ox Permanent or 13Temporary Sim ertified Well Contractor Date
By signing this form,1 hereby certify that the"11(5)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or X)No with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out know»well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 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-I 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: 385 (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@100) construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
If Knter revel is above caring,use"+•' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection 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
13s.Yield(gpm)7 Method of test:Weir 24c.For Water SuDDIy&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:chlorine Amount: 18 oZ 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 2-22-2016