GW1--04335_Well Construction - GW1_20240722

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: —
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4449-A 300 ft. 400 fL 2 GPM
500 ft. 565 ft. 1.5 GPM
NC Well Contractor Certification Number IS.OUTER CASING for mold cased weI�OR LINER If a Ilcabie
Rowan Well Drilling FROM TO DIAMETER — THICKNESS MATERIAL
Company Name ,I (] Q 0 �• 104 ft• 6 1/4 i°_ SDR21 PVC
2.Well Construction Permit#:oswp202446906 1FRROM CASING OR TUBDIAMEMA ermalclosed-loop)MMATERIAL
List all applicable well construction permits(,.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 31,4C1TSIZE THICKNM MATERIAL
Agricultural OMunicipal/Public 0 ft. fL in.
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft —
. ft. In.
Industrial/Commercial Residential Water Supply(shared) —
18.GROUT _
Irrigation FROM I TO MATERIAL _ EMPI.ACEM. FONT METHOD 6 AMOUNT
Non-Water Supply Welt: 0 ft. 20 ft. Hole lu _ Gravity 7 bags
Monitoring DRecovery fL fL
Injection Well: ft. IL —
Aquifer Recharge ©Groundwater Remediation 19•SAND/GRAVEL PACK if a IlcableL
Aquifer Storage and Recovery [3Sahnity 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 neck
Geothermal (Heating/Cooling Retum Other(explain under#21 Remarks FROM TO DESCRIPTION I.otor,kanlaesi6 willmit typp,Vain dza,etc.0 ft. 15 ft. Clay
4.Date Well(s)Completed:6/20/2024 Well]D#202446906 15 ft. 70 ft. sandy overburden
5a.Well Location: 70 fL 94 ft- weathered rock
IQ Customs 94 ft. 104 ft. solid rock
Facility/Owner Name Facility ID#(ifapplicable) 120 ft- 140 ft. various Drown veins
115 Ridgecliff Dr, Statesville 28677 ft. ft. —_
Physical Address,City,and Zip ft. ft. !
Iredell 4710 65 7925 21.REMARKS
Cotuity Parcel Identification No.(PIN) wateF eleafed _
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: —
(if well field one lat/long is sufficient)
22.Certification: Uf:',.::s%.�
35 40 26.935 N 80 57 49.777 W k � J-211� L ) z t) f z`t
6.Is(are)the well(s)ex Permanent or OTemporary rgnature of ified Well Contractor — Date
By signing this form,I hereby certify that the we/l(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 knovm well construction information and explain the nature of the copy of this record has been provided to the ivell 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 565 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(exmnple-3@200'and 1@1000 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,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
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 push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test:weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 26 OZ the address(es) 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-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016