GW1--06201_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George James Brown III 14.WATER ZONES
Well Contractor Name
TO DESCRIPTION I
4654-A 58 f. 60 1t, 6 GPM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi--cased wells)OR LINER(If ill !able)
Rowan Well. Drilling FROM TO DIAMETER I. THICKNESS
HATER AL
0 ft* 55 61/4 m: SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-1mm)•
2.Well Construction Permit#:'A t VA FROM TO DIAMEtEFt ,TmCKNESS MATERIAL
Lint all applicable well construction permits(i.e.UIC,County,Stab Variance,etc.) ft. ft. In
3.Well Use(check well use): ft' ft' in.
Water Supply Well: SCREEN
FROM TO DIAMETER. SLOT SItE THICKNESS MATERIAL
d Agricultural QMunicipal/Public 0 tit ft. In. ,
QGeothennai(Heating/Cooling Supply) QResi_dential Water Supply(single) ft, it. in. •
Qlndustrial/Commeneial OResidential Water Supply(shared) 19.GROUT
frndgation FROM TO MATERIAL ! EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 ft. Holeplug ` Gravity 15 bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft. •
QAquifer Recharge OGroimdwater Remediation
19.SAND/GRAVEL PACK(If applicable)Aquifer Storage and Recovery !Salinity Barrier FROM TO. MATERIAL f EMPLACEMENTMETHOD
Aquifer TestExper Stormwaler Drainage
Geothermal
l Technology [Subsidence Control ft.ft
1L
Creothetnrai(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heats ng/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSCRIPIION(color,nuaam saihnetc type,grain size,etc.)
0 ft' 20 ft' Dirt/tan,rock
4.Date Well(s)Completed:9/11/24 well m#NA _ 20 ft. 40 L Solid Rock'
5a.Well Location: 40 ft: 55 ft' Solid Rock
Beth Smith - ft. 55 fa Set casing •,_ ___
',
Facility/Owner Name Facility ID#(ifappliiiable) f6 ft. -r.L.. .k;,�>'i.:'e 41 i.
275 Linker Rd, Rockwell ft. ft.
Physical Address,City,and Zip
ft. I, OCT 2, ? 2024
Rowan NA 21.REMARKS I tr,j,,,. .
r.,;
County Parcel Identification n No.(PIN) Ct i; : i k;
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one let/long is sufficient) 22.C cation:
35 5.6 5400 N 80 36 7690 w fi0 -'— R l it 1 z4
6.Is(are)the well(a)0Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)um(were)constructed in accordance
7.Is this a repair to an existing well: QYes or uiNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out brown well construction information and explain the nature of the copy ofthis record has been provided to the riell'owner-
repair under MI remarks section or on the back of thitform. 23.Site diagram or additional well details:
IL 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: 125 I (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrerent(example-3®200'and2Q100) construction to the following: i
10.Static water level below top of casing:40 I (ft.) Division of Water Resources,Information Processing Unit,
If water level is above easing,use"+" I 1617 Mall Service Center,Raleigh,NC 27699-1617
IL Borehole diameter:6 (in.) I 24b.For Infection Wells: In.additio r to sending the limn 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.) M
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)6 Method of test:Weir 24e.For Water Snooty&Infection Wells: In addition to sending the form to
the addresses) above,also submit one copy of this form within 30 days of
13b.Disinfection type:Chlorine Amounh 6 OZ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016