GW1--05078_Well Construction - GW1_20240827

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
George Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4654-A 105 it 125 ft. 2 GPM
405 ft 425 ft• 1 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wetl�OR LINER(If ap Deable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 47 ft. 61/4 In. SDR21 PVC
Company Name _
W 24 22 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 DMunicipal/Public 0 ft* it. in.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft rt. in.
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0 ft- 21 ft
Holeplug ^ Gravity 15
Monitoring DRecovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK Of applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION((Mar,hardness,solVach type,pale du,etc.)
(H g/ g Other(explain under#21 Remarks) [t35 R
• dirt
4.Date Well(s)Completed:7/11/2024 Well m#W 24 22 35 ft. 47 ft' Solid Rock
5a.Well Location: - ft 47 ft' casing set
Jareth Koontz ft ft.
_ .1
Facility/Owner Name Facility ID#(if applicable) ft. ft.
405 Luna Lane, Clemmons ft. ft. — 7r
Physical Address,City,and Zip ft. ft. — J6 �`
Davidson 0301600000017K 21•REMARKS ►r.4:, .L.i:... A- sal.. 1;a
County Parcel Identification No.(PiN) O ` --a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 22, ' cation:
35 57 53.404 N 80 20 0.3191W
✓L � __. — rl Z %/
6.Is(are)the well(s)iX Permanent or [)Temporary Signature of Certified 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 XONo 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#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:1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 445 (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 file 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
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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test:Weir 24c.For Water Snooty&Infection Wells: in addition to sending the form to
chlorine 21 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 OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016