GW1--04348_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 DESCRIMON
111 ft• 130 ft• 3 GPM
4449—A 525 fL 540 ft. 4 GPM
NC Well Contractor Certification Number 15,OUTER CASING for could-sated wlils OR LINER if ap linable
Rowan Well Drilling FROM To DIAMETER— THICKNESS MATERIAL
0 ft• 110 ft• 61/4 '°• SDR21 PVC
ca 'y Name 16.INNER CASING OR TUBING eottermal closed-1
WELL 240223 01
2.Well Construction Permit#: FROM TO DIAMETER —_ THICK.NESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State, Variance,etc.) ft. ft. a
3.Well Use(check well use): ft ft °
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 5IAYr SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. I ft. in• —
Industrial/Commercial Residential Water Supply(shared) —
lg.CRO[Tf Irrigation FROM I TO MATERIAI. _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft- Holeplu _ Gravity 14
Monitoring DRecovery fa ft.
Injection Weil: —
ft. ft.
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK H Iteable
Aquifer Storage and Recovery QSalinity Barrier FROM I To I MATERIAL — EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach addldonal sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO I DESCRIPTION color bud .11/o k type,grain etc.)
0 fL 20 ft. Clay
4.Date Well(&)Completed:6/27/2024 Well ID#240223 01 20 rt 80 ft Sandy Overburden
5a.Well Location: 80 ft 105 ft Weathered Rock
Kurt Singleton 105 ft 110 ft• Solid Rock
Facility/Owner Name Facility ID#(ifapplicable) Ill ft• 113 ft• Brown vein
7768 Lynwood Lane, Sherrills Ford 28673 iL ft• _ - ._
Physical Address,City,and Zip It. ft. ll L �UZ
Catawba 460604715796 21.REMARK
County Parcei Identification No.(PIN) fArfiWill
:
-tis .-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cerdflcadon:
35 33 6.644 N 80 59 29.042 W 12- 7 I Z
6.Is(are)the well(s)Ex Permanent or OTemporary S'ngnatnre o er ificd 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: ©Yes or )No with ISA NCAC 02C.0100 or 1 SA 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 welt owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well deta{Is:
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:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diferent(exmnple-3(,200'and 2Qa l M construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Iniection 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)7 Method of test•weir 24c.For Water Supply&Infection Weir: 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: 28 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