GW1--04354_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 DESCRIPTION
4449-A 44 ft. 425 ft• 1/2 GPM
425 ft 605 ft. 1/4 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of ap llcable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 44 ft. 61/4 In. SDR21 PVC
Company Name —
cha we 2024 00040 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.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 SLOT SIZE THICKNESS MATERIAL
Agricultural ()Municipal/Public 0 ft. ft. in
Geothermal(Heating/Cooling Supply) XnResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation PROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Holeplug Gravity 9
Monitoring Recovery ft. ft.
injection Well: —
Aquifer Recharge QGroundwater Remediation19 (if applicable)
Aquifer Storage and RecoverySalini Barrier SAND/GRAVEL PACK
q $ � ty FROM TO MAiER1A1. EMPLACEMENT METHOD _
Aquifer Test DStormwater Drainage fL fL
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheet,if necessary)
FROM TO DESCRIPTION(color,bardams,soWrock type,grain du,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft- 5 ft- Clay
4.Date Well(s)Completed:4/29/24 Well ID#202400040 5 ft. 18 ft. Shale
5a.Well Location: 18 t° 43 t SoliclRock/slate
Michael Fusco ft. ft. _ V 7 ��
Facility/Owner Name Facility tD�l(if applicable) ft ft' - `.'- ! ,1� '
5030 Cauble Rd, Mt Pleasant 28124 ff. ft. _ V
Physical Address,City,and Zip ft. ft. 2
Cabarrus 21.REMARKS
aw'-=,Ulta
County Parcel identification No.(PIN) j,h`4 SCA
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 Certification:
35 20 53.980 N 8o 24 29.126 W � 4 L q17_ i
6.Is(are)the well(s) x Permanent or Temporary Signature of Certifiad�ll ell Contractor Date
By signing this form,1 hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ❑X No with ISA NCAC 02C.0100 or iSA 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 well owner.
repair under 421 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:1 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 different(example-3@200'and 2@100) 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 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3/4 Method of test:weir 24c.For Water Supply&Inleition Wells: In addition to sending the form to
chlorine 1.75 lbs 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 G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016