GW1--04347_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 DFSCRIPTION
4449-A 56 ft. 200 fL 2 GPM
300 ft 400 ft' 4 GPM
NC Well Contractor Certification Number 13.OUTER CASING for multi-easetd well's OR LINER if a Duble
Rowan Well Drilling FROM To I DIAMETER 7H(CICVESS MATERIAL
Company Name 0 It. 56 ft- 1 6 1/4 it J SDR21 PVC
W 23 72 16.INNER CASING OR TUBING eotherma►closed-loop)
2.Well Construction Permit#: FROM To DIAMETER TIHOLNESs I MATERIAL.
List all applicable well construction permits#,e.UiC,County,State,Variance,etc.) ft• ft• in.
3.Well Use(check well use): fL
Water Supply Well: 17.SCREEN
FROM TO I DtA_METER SLOTSIZE TLHCV-NM MATERIAL
Agricultural []Municipal/Public 0 ft ft. In,
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft. In
-
:)Industrial/Commercial Residential Water Supply(shared) 18.GROUT _
Irri ation FROM TO MATERIAL _ EMPLACEMUNT METHOD&AMOUNT
Non-Water Supply Well: 0 fc 20 ft. Hole lu _ Gravity 6 bags
Monitoring ORecovery ft. ft.
Injection Well: -
Aquifer Recharge Groundwater Remediation _
19.SANDlGRAVEL PACK if• Ruble
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LAG attach additional sheets if necessary)
r
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks FROM TO DESCRIPTIO.i1oolor hardwU kro1adetc.0 it. 18 ft. Clay/shale
4.Date Well(s)Completed:5�22�24 Well ID#W 23 72 18 fc 30 ft. Shale _
5a.Well Location: 30 ft. 46 ft. Slate/shale
Hedrick Creative Builder 46 fL 56 ft- Solid Rock!slate
Facility/Owner Name Facility III#(if applicable) ft. ft.
175 Harbor Dr W, Lexington ft. R
Physical Address,City,and Zip ft ft•
Davidson 09022A00000033 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.eCertiHcation•
35 37 11.991 N 80 13 2.247 �
6.Is(are)the well(s)E% Permanent or Temporary Signatute
of Certified Well Contractor Date 1I
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an ezisting well: ®Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 01C.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 wedl 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:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft-) 24a. 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@I00) 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,rise••+" 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
12.Well construction method: rotary rota 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)6 Method of test:Weir 24c.For Water Supply&In)ectfon Wells: In addition to sending the form to
chlorine 20 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revived 2.22-2016