GW1--05966_Well Construction - GW1_20241009

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WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only:
1.Well Contractor Information:
Spencer Adams
FROM TO DESCRIPTION
Well Contractor 131 ft. 300 D• 2 GPM
4449-A 340 n 400 it. 3 GPM I I
NC Well Contractor Certification Number .15i OUTERCASING(for.multl.ased*ells)OR LINER(if ap sable):' : :.. .
Rowan Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
0 it 131 . n• 61/4 i°• SDR21 PVC
Company Name 1.16.INNER CASING.ORTiJBING(Rmthermil dated loon) :: `.
2.Well Construction Permit it:14302: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County.State,Variance,etc) ft. ft. In.
3.Well Use(check well use): D. It' m.
17 SCREEN:
Water Supply Well:
FROM TO DIAMETER SLOT BITE THICKNESS MATERIAL
Agricultural °Municipal/Public 0 it ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) g, ft. in. i
Industrial/Commercial DResidential Water Supply(Blared) .:1&GROUT<:. •. .•..• ..:•:•:i: •. :. :•. '' .
Irrigation FROM TO + MATERIAL I EMPLACEMENT METHOD&*mum
Non-Water Supply Well: 0 ft• 20 ft. HOleplug Gravity 10
Monitoring °Recovery ft. ft.
Injection Well: R. g.
Aquifer Recharge DGrot mdwater Remediation
192 SAND/GRAVEL'PACK(If applicable)' :.. .`.
Aquifer Storage and Recovery °Salinity Barrier .FROM TO MATERIAL . EMPLACEMENTME7HOD
Aquifer Test DStormwater Drainage ft. ft. . ,
Experimental Technology OSubsidence Control ft. it
Geothermal(Closed Loop) OTracer 20:DRILLING LOG(xthch'additiohaletnzle Ifneces;sity): :.:•: .:. `: ,
FROM TO DESCRIPITON(colon bWaess.wWmektsPni ndMaeta)
Geothermal Meating/Cooling Return) nOther(explain under#21 Remarks) 0 ft 20 Clay jf
8112124
4.Date Well(s)Completed: Well ID#14302
20 ft 100 n' Sandy Overburden
Se.Well Location: 100 ff. 123 Weathered Rock •.
Caruso Homes 123 ft 131 ft Solid Rock `.ti 't., F % i i .. .
131 ft. 300 lt• Various Soft Veins r
FaclGty/OwnerNema Fac�7[tyn?#(if applicable) � ft. OCT 011 1, 2024
5139 Kings Pinnacle Dr, Kings Mt
Physical Address,City,and zip fit. ft Ire v:F :r'�.• :::>
Gaston 3513 01 044E E1 : : U
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one let/long Is sufficient) 22.C titication: ,
.3511 18.662 N 81 18 34.384 w ({z. 12.K
6,Is(are)the Weli(s))x Permanent or Temporary Signature o Certified Well Contractor I ' Date
.fly signing this form,I hereby certh that the'wrll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 3 No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out known well construction information and captain the nature of the copy ofthis record has been providedto the well owner.
repair under#21 remark sectIon or on the back of this form. 23.She 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 detals. You may also attach additional pages if necessary.
drilled:1 SUBMI'1'TA.L INSTRUCTIONS
9.Total well depth below land surface:405 (ft.) 24a.For All Wela: Submit this four within 30 days of completion of well
For multiple wells list ail depths(fd different(example-3Qa 200'and2@100') construction to the following:
1
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
if miter level is above casing use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (li.) 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)5 Method of test:weir 24c.'Or Water Supply&Infection Wells: In addition to sending the form to
the addtess(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection type:chlorine Amormt: 19 OZ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironmental Quality-Division ofWaterResources Revised 2-22-2016