GW1--06895_Well Construction - GW1_20241118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
George Brown III • 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4654-A 285 ft. 305 ft• 1 GPM I i
405 it. 425 ft. 1 GPM f '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Rowan well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 149 ff. 61/4 f°• SDR21 PVC
2024 48272 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.U1G County,State,Variance,etc.) ft• ft. In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft ft In.
Geothermal(Heating/Cooling Supply) xi[)Residential Water Supply(single) ft, ' ft. In.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. Holeplug Gravity 10
Monitoring Recovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remedialion 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT 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#21 Remarks) FROM TO DESCRIPTION(eolo,Warding/veil/rock type Qraln etc.)
0 ft. dirt 1
4.Date Well(s)Completed:10/28/24 Well m#202448272 80 ft 120 ft. dirt/rock
Sa.Well Location: 120 ft• 140 ft rock I:
Stephan Shangle 140 ft' 149 ft solid rock - •�•- ; . -- •
Facility/Owner Name Facility 1D#(if applicable) ft ft. . .'‘.;:..,-. S,,,'k.r .• '2......
591 Shiloh Rd, Statesville ft ft NOV 1 S 2024
Physical Address,City,and Zip ft ft.
Iredeil 4752 76 0512 21.REMARKS
County Parcel Identification No.(PIN) l :,' '' +2)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one'at/long is sufficient) 2 ertification:
35 732339 N 80 830263 W t Q lJX i
6.Is(are)the well(s){X Permanent or Temporary Signature of Certified Well Coo r i Date
By signing this form,I hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: DYes or id No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repay,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. I
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. .
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:425 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@200'and 2Qa 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
13a.Yield(gpm)2 Method of test:weir I
24c.For Water Supply&Injection 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: 18 OZ completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources e Revised 2-22-2016
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