GW1--05079_Well Construction - GW1_20240827

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 111 ft. 340 ft. 1/2 GPM
340 ft. 370 ft. 2.5 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-wed wells)OR LINER(If a liable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 111 ft. 61/4 1°- SDr21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well W 24 26 Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft. hi.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO
Agricultural QMunicipallPublic ft.
ft.Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. It. DIAMETER SLOT SIZE THICKNESS MATERIAL
In.
,IndustriallCommercial OResidential Water Supply(shared) --
is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• HOlepku9 Gravity 6
E3Manitoring ORecovery ft ft. -"
Injection Well: ft. ft.
,
Aquifer Recharge QGroumdwater Remediation _
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL CEMENT METHOD
Aquifer Test QStormwater Drainage It. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets If necessary:
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(whir,Yardman,soWnea type,grids aIre,etc.)(H g/C utg ( Other(explain under#21 Remarks) 0 ft' 20 ft• Clay
4.Date Well(s)completes:7112124 Well 1D#W 24 26 20 ft. 90 ft. Sandy Overburden
5s.Well Location: 90 ft. 106 ft• Weathered Rock
Jose Penaloza 106 fL 111 ft• Solid Rock
Facility/Owner Name Facility 1D#(if applicable) ft• ft.
469 Shoaf Rd, Lexington ft ft. — li y 1'7
Physical Address,City,and Zip ft. It
Davidson 0400500000012 21.REMARKS ; ,,tl 2 ?Q24
County Parcel Identification No.(PIN) k.f4:
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce cation: i
35 48 11.021 N 80 27 30.843 W - ?i I z I-
6.Is(are)the well(s)OPermenent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certtfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or XQN° with 15A NCAC 02C.0100 or/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 well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'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 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotaryabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)3 Method of test:weir 24c.For Water SUDD1v&Infection Wells: In addition to sending the form to
Chlorine 19 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016