GW1--05099_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
Well Contractor Name FROM TO DESCRIPTION
4449-A 75 ft. 150 ft• 1.5 GPM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cued wells,OR LINER(if sp Ilcable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 74 ft. 61/4 In• SDR21 PVC
Company Name OSWP 2024 52292 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit N: FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
i FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic 0 ft. ft. In.
Geothermal(Heating/Cooling Supply) X)Residential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft• 20 ft• Holepiug Gravity 9
Monitoring DRecovery ft. ft.
Injection Well: --. j
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicatdc)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DTrac,er 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bard.,,,toll/rock type grain sloe,etc.)
0 ft- 18 ft• Clay
4.Date Well(s)Completed:7/3/2024 Well ID#52292 18 ft• 38 ft. Sandy Overburden
Sa.Well Location: 38 ft• 69 ft. Weathered Rock
Todd Atwell 69 ft. 74 ft• Solid Rock
Facility/Owner Name Facility ID#(if applicable) ft. ft. *'.
145 Piney Grove Rd, Harmonyi 1 - 3
ft ft.
Physical Address,City,and Zip ft, ft. AUG 2024
Iredell 4799 19 8369 21.REMARKS
Ji.''
County Parcel Identification No.(PIN) _ �
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 56 3.698 N 80 42 57.822 W . � ! ,
i
6.Is(are)the well(s)jx Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certtb,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONo with 1 SA 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 GeoprobefDPT 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 atrach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (t) 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: (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
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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1•5 Method of test:weir 24c.For Water Saopiv&Injection 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 G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016