GW1--06223_Well Construction - GW1_20241021

PrritForm_~'1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George Brown Ill 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION'
4654-A 365 ft. 385 ft. 5 GPM
ft ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multl-cased wells)OR LINER(If ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft: 60 ft. 61/4 'fn• .185 steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
59191
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) 0 ft. 105 it. 4 in. sdr21 pvc
3.Well Use(check well use): ft ft is
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft ft in. '
Geothermal(Heating/Cooling Supply) [)Residential Water Supply(single) ft. ft. ln.
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• holeplug gravity 4
Monitoring C3Recovery ft ft.
Injection Well:
u Recharge R ,
Aquifer barge Groundwater Rtanediation --
Aquifer Storage and Recovery Salinity Barrier aR SAND/GRAVEL PACK MAa MATERIAL
EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft.- ft. I'
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain du,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 f6 35 ft• dirt
4.Date Well(s)Completed:9/19/24 Well lD#59191 35 fL 50 ft: dirt/brownrock
5a.Well Location: 50 fc 60 ft' solid rock
Melissa Murdock 60 fd 80 ft. soft brown rock cv 'ir,,r." ,11_:_t. 1 •
Facility/Owner Name FacilityID#(if applicable) 80 ft. 425 f black/brown rock
201 Tucker Rd, Statesville ft. ff. OCT 2 I ?OZ-
Physical Address,City,and Zip ft. ft.
Iredell 4752 31 6921 21.REMARKS
1.0 ri,t,v'si-,.9
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.C cation:
35 719570 80 840590 l
N W . -. .- ' l i t i z�/
6.Is(are)the weil(s)IJPermanent or r3Temporary Signature of Certified Wel oatmctor 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: DYes or IONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fall out known well construction information and explain the nature of the copy of this record her 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.
filled't SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:425 (fw) 24a. For All Wells: Submit this form within 30 clays 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
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
I,
1;
13a.Yield(gpm)5 Method of test:weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 18 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016