GW1--06240_Well Construction - GW1_20241021

i Prin#Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George J Brown III ,14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
4654-A 65 ft• 80 ft. 10 GPM t
125 fr. 145 ft- 15 GPM 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER ,
Rowan Well Drilling (S llMATE-
FROM 7'. _ DIAMETER" THICKNESS MATERIAL
Company Name 0 ft' 57 ft. 61/4 In. SDR21 PVC
2.Well Construction Permit#:
240 726 02 J M B 3605 1166.o�ER CASING ORTUBDIN eeoothermal��sg) MATERIAL
List all applicable well construction permits(i.e.UlC County,State,Variance eta) ft ft. in.
3.Well Use(check well use): R' j°•
Water Supply Well: 17.SCREEN ' . „
FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
Agricultural lMunicipal/Public 0 ft ft. in. ;;
Geothermal(Heating/Cooling Supply) xOResidential Water Supply(single) ft ft. in.
Industrial/Commercial C3Residential Water Supply(shared) 18.GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n 3 ft Bentonite Pumped 1
Monitoring EDRecovery 3 ft 54 ft Slur Pump 11
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediatioa
19.SAND/GRAVEL PACK Of applicable) - •
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I. EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft. j
Experimental Technology OSubsidence Control it ft. I
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,gain sure,etc.)
Geothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks) 0 it 40 dirt/brown rock
4.Date Well(s)Completed:9/24/24 Well m#24072602 40 n 57 solid rock '
5a.Well Location: - ft 57 ft set casing
First In Flight Construction 60 ft 125 ' black/pink rock
Facility/Owner Name FacilitylD#(ifapplicable) 125 n 185 ft pink rock/quartz; r,-,^-z - - -
5054 Mallard Cove, Sherrills Ford
fG ft. & -.f
.(t,.,>'E....; '. a, a. a
Physical Address,City,and Zip ft ft. OCT r, 2 I 2021
Catawba 461603036550 21.REMARKS
County Parcel Identification No.(PIN) Ir-.`^•- P'^^'�,"'" r sfx
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f,''e a t ••td a
(if well field,one lat/long is sufficient) 2 Certification: i
35 557168 N 80 981737 W / ;; Q
6.Is(are)the well(s)1x Permanent or OTemporary 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: DYes or 1_INo with 15A 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 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.
hued'1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Qa 100') construction to the following: •
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
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:
(ie.auger,rotary,cable,direct push,etc.) I,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm)25 Method of test Weir 24c.For Water Sunni*&Injections Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:chlorine Amount: 9 OZ completion of well construction to the county health department of the county
where constructed i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016