GW1--05091_Well Construction - GW1_20240827

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4449-A 143 250 ft• 1 GPM
370 ft. 400 ft* 11 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Rowan Well Drilling FROM TO DIAMETER _THICKNESS MATERIAL
0 it 143 ft• 61/4 In. _SDR21 PVC
Company Name
14289 16.INNER CASING OR TUBING(geothermal dosed•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 SITE THICKNESS MATERIAL
Agricultural DMunicipaUPublic 0 fts ft. in.
Geothermal(Heating/Cooling Supply) XDResidential Water Supply(single) ft, ft. In.
Industrial/Commercial EDResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACE.MENr METHOD A AMOUNT
Non-Water Supply Well: 0 it• 20 ft• Holeplug _Gravity 5
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If oKaeery)
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TD DESCRIPTION(color,hardness,mama type grata u se.etc.)
0 it. 12 it. Clay
4.Date Well(s)Completed:7/2/2024 Well ID#14289 12 1t. 13 ft' Sandy Overburden
5a.Well Location: 130 it• 138 ft Weathered Rock
Local Knowledge Invest 138 it. 143 ft• Solid Rock _
Facility/Owner Name Facility ID#(if applicable) 149 ft. 153 ft• Soft Rock
339 Sunderland Rd, Belmont ff. ft. '± '' ' 1
Physical Address,City,and Zip ft ft.
A U G I - 20?4
Gaston 3593 61 4712 21.REMARKS
,rr
County Parcel identification No.(PIN) !,..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35 11 38.354 N 81 1 12.926 W l Z�'
r—� '
6.Is(are)the well(s)E% Permanent or Temporary Signature of�ertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.la this a repair to an existing well: DYes or XDNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this Ls 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 Weill: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3( 200'and 241100') construction to the following:
10.Static water level below top of casing:50 (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 Injectlon 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) 12 Method of test:weir 24c.For Water Supply&Injection Weill: 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: 19 OZ 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 Revisal 2-22-2016