GW1--05082_Well Construction - GW1_20240827

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
SPENCER ADAMS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 96 ft. 118 ft 4 GPM
4449-A I rL ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-wed wells)OR LINER Of ap llcable)
Rowan Well Drilling FROM TO DIAMETER T,UCIQiESS MATERIAL
0 ft- 86 ft- 6 1/4 t°J SDR21 PVC
Company Name W 24 12 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,Stale,Variance,etc.) ft. ft. ier
ff. ft. la.
3.Well Use(check well use):
1Supply Well: 7.SCREEN
Water Sa
PP•7FROM TO DIAMETER SLOT 817E THICKNESS MATERIAL
ciAgricultuual DMunicipal/Public 0 ft' ft. In.
QGeothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft, ft. la
Qlndustrial/Commercial OResidential Water Supply(shared) 18.GROUT _
Ilhrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, Holeplug Gravity
°Monitoring ORecovery ft. ft.
Injection Well: ft ft,
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)i
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage f ft. _
Experimental Technology OSubsidence Control ft. It.
Geothermal(Closed Loop) EjTracer 20.DRILLING LOG(attach additional sheets if necessary)
PROM TO DESCRIPTION(color,Ludlum,wltrock type,Enter size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under 821 Remarks) 0 ft 12 ft clay
4.Date Well(s)Completed:7/19/24 Well ID#W 24 12 12 ft- 81 ft. boulders/clay/fractured rock
Sa.Well Location: 81 ft. 86 ft' solid rock
Cameron Rose 96 ft. 104 1I brown vein
Facility/Owner Name Facility lD#(if applicable) 111 ft. 120 ft• Brown vein •---
23050 NC HY 109, Denton ft i,i,
W
Physical Address,City,and Zip ft. ft. AUG 2 �- 9A�A
Davidson 0200500000019 21.REMARKs LU 4
County Parcel Identification No,(PIN) ,,t'. g 1-h»y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G
(if well field,one lattlong is sufficient) 22. edification: •
35 33 42.053 N 80 546.290 W ��! ,..,V.,t
r / 1 g i Z
6.Is(are)the wells)f 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 oNo with 1 SA 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 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: 405 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferent(example-3(§200'and 2Qa 101Y) 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 caring,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) Method of test:
5 weir 24c.For Water Sunlit,/&Infection Well: 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: 18 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