GW1--05115_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 320 ft. 340 ft* 12 GPM
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING(for multi-caned wells)OR LINER(If ap Ilcable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft• I
104 ft• I 6 1/4 in. SDR21 JPVC
24-176 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. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
°AgriCUltural FROM TO DIAMETER K.N
SLOT SIZE TLLICESS MATERIAL
®MunicipalPublic 0 ft, ft in.
jGeothermal(Heating/Cooling Supply) XDResidential Water Supply(single)
ft. ft in.--'
jIndustrial/Commercial °Residential Water Supply(shared) —
18.GROUT
Irrigation FROM TO MATEAI AL EMPLACEMENT
Non-Water Supply Well: 0 ft 20 ft• Holepluq Gravi METHOD&AMOUNT
Injection Well: ty 7
Monitoring Recovery ft
ft.
uifer Recharge ft. ft —�
A
q °Groundwater Remediation
Aquifer Storage and Recovery QSalinity Barrier19.SAND/CRAYEL PACK Ot applicable)
FROM TO MATERIAL METHOD
Aquifer Test DStormwater Drainage ft ft.
Experimental Technology °Subsidence Control ft, ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) °Other(explain under#2I Remarks) FRost ro DESCRIPIToti(color,bassl.eu soil/rodetype grata sir etc.)
7/1/2024 24-176 ° ft.
ft.
Red Clay
4.Date Well(s)Completed: Well iD# 20 ft 90 ft.
sa.Well Location: k Shale!t;a�/sand
JoMar Construction 90 ft. ft* WeatheredkRock
99 104 ft- R
Solid Rock
Facility/Owner Name Facility iD#(if applicable) 106 ft. 110 ft. Brown Rock ..
1910 Irby Rd, Monroe ft. ft. AUG 2, 'i [024
Physical Address,City,and Zip ft. ft.
Union 04 234 005 21.REMARKS .r` t
County Parcel Identification No.(PIN) • '
sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
34 52 24.329 N 80 35 46.746 22.Certification: /
w
•
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: ©Yea or It°No with ISA NCAC 02C.0100 or ISA NCAC 0.2C.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 Cloned-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: 365 (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 l00')
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 Infection 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&Inlection Rgll2: In addition to sending the form to
chlorine 12 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-I North Carolina Department of Envirorunental Quality-Division of Water Resources
Rettised2-21.2016