GW1--04337_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 ZONES
FROM TO DESCRIMON
Well Contractor Name 53 ft• 400 ft- .5 GPM _
4449-A 400 ft- 500 ft• 1.5 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi caul wells OR LINER f a Ilcable
Rowan Well Drilling FROM TO DIA ETER TlllctavEss MATERIAL
0 fL 53 ft- 61/4 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-1
2.Well Construction Permit M OSWP202451378 FROM TO DIAMETER THICICYFSS MATERIAL
List all applicable well construction permtls(i.e.UIC,County,Stale,Variance,etc.) ft' ft. In
ft.
3.Well Use(check well use):
Water Su FR SCREEN _
PP1Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS :MATERIAL
Agricultural [)Municipal/Public 0 fL fL in,
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) fL ft. In.
Industrial/Commercial Residential Water Supply(shared) i8.GROUT
Irri ation FROM 70 MATERIAL _ EMPLACEMUNT METHOD k AMOUNT
Non-Water Supply Well: 0 ft- 20 It Holepiug_ Gravity 6 bags
Monitoring Recovery ft. ft-
Injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation -
19.SAND/GRAVEL PACK if applicable]
Aquifer Storage and Recovery QSalinity Barrier FROM TO '.MATERIAL _ EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft ft _
Experimental Technology Subsidence Control >w ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain tinder#21 Remarks FROM TO DESCRIP'r70!�kcobr,baMsaa,«tvroer<type, rat, etc.
0 ft- 20 ft- clay
4.Date Well(s)Completed:6/18/2024 Well iD#202451378 20 ft- 43 ft- sand overburden
5a.Well Location: 43 ft' 53 ft- solid rock
Northlake Developers ft. ft• __
Facility/Owner Name Facility ID#(if applicable) ft
149 Shady Cove Rd, Troutman ft. R.
Physical Address,City,and Zip ft n
Iredell 4730 71 4573 21.REM"'KS
County Parcel Identification No.(PIN) 1 7'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: fit/^-3CI `
(if well field,one tatAong is sufficient) 22.Certification:
35 39 45.972 N 80 53 38.834 W +�, n ( `; ! ,S- ,a
6.Is(are)the well(s)Ex Permanent or Temporary •signature of Ckified Well Contractor Date
By signing this form,I hereby certify that the wells)war(were)constructed in accordance
7.Is this a repair to an existing well: QYes or X)No with 15A NCAC 01C.0100 or 1 SA NCAC 01C.0100 Well Construction Standards and that a
If this Is a repair,fill out kno"well construction information and explain the nature of the copy ofthis record has been provided to the iveli owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well di talls:
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-1 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: 505 (ft•) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lit dierent(example-3@200'and 2@1060 construction to the following:
10.Static water level below top of casing: YL) Division of Water Resources,Information Processing Unit,
Ifventer 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 IDJectlon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)2 Method of teat:Weir 24c.For Water SuoDiv&Inlection Wells: In addition to sending the form to
the address(es) above, also submit cne copy of this fort within 30 days of
13b.Disinfection type:chlonne Amount: 23 oZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Departuxnt of Environmental Quality-Division of Water Resources Revised 2-22-2016