GW1--05081_Well Construction - GW1_20240827

Print Form I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
100 ft 200 ft. 20 GPM
4449-A 200 ft 240 ft- 15 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cued wells)OR LINER(if ap licable)
Rowan Well Drilling FROM TO DIAMETER_ THICKNESS MATERIAL
0 ft 44 ft. 61/4 in. SDr21 PVC
Company Name
W 24 27 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. hi.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgriculttual DMunicipalfPublic ft. ft in.
Geothermal(Heating/Cooling Supply) %)Residential Water Supply(single) ft. ft in,
QlndustriallCommercial DResidential Water Supply(shared) 18.GROUT
I,Irrigation FROM TO MATERIAL-' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft- HOleplug Gravity 6
Monitoring DRecovery ft ft.
Injection Well: ft. ft —
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL_ EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
QExperimental Technology DSubsidence Control ft ft.
BGeothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness,con/rock type,grila Us etc.)
0 f- 18 ft- Clay
4.Date Well(s)Completed:7/17/24 Well m#W 24 27 18 f- 43 f- Solid Rock
5a.Well Location: 100 it 120 ft. 5 gpm —
James Collins 180 f- 200 ft. 15 gpm
Facility/Owner Name Facility ID#(if applicable) 200 ft- 240 ft. 15 gpm
589 Hunt Rd, Lexington ft ft. _ . c,_. , ,, ,
Physical Address,City,and Zip ft. ft. 1'G 2 7
2021
Davidson 091700000004 21.REMARKS U�+
County Parcel Identification No.(PIN) = R"r"af'+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22, ertifieadon•
35 37 2.151 N 80 8 52.882 W L� k '-) 1 // / 2 C\
6.Is(are)the well(s)Jx 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: DYes or IDNo with 15A NCAC 02C.0100 or 15A 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 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: 325 (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:20 (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)35 Method of test:weir 24c.For Water SuoDly&Injection Wells: 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: 15 OZ 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