GW1--06898_Well Construction - GW1_20241118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George Brown Ill 14.WATERZONES I I
Well Contractor Name FROM TO DESCRIPTION
4654A 180 ft• 200 fA 6 GPM
ft. ft.
NC Well Contractor Certification Number 1S.OUTER.CASING(for multi-caned wells)OR LINER(If op llcable)
Rowan Well Drilling FROM To DIAMETER TIIICIavEss MATERIAL
Company Name 0 ft` 88 ft61/4 f°• SDR21 PVC -
2024 57437 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. R. In.
3.Well Use(check well nee): fI. R. I In.
Water Supply Well: 17.SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. In.
Geothermal(Heating/Cooling Supply) %DResidential Water Supply(single) p, ft. In.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug GRavity 10 GPM
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK
Aquifer Storage and Recovery {Salim Bather (if pliIable)
LJ tY FROM TO MATERIAL EMPLACEMENT METHOD
quiferTest DStormwaterDtainage ft. f
Experimental Technology 0Subsidence Control ft. ft. 1
Geothermal(Closed Loop) :Placer 20.DRILLING LOG(aftacliáddltl htetslinccess )
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRtPrION(color,n.rdaesx soil/rock type,grain sIza ate.)
4.Date Well(s)Completed:10/7124 Well 2024 57437 0 ft. 70 ft. dirt I Pro' wi nn rock
5a.Well Location: • 70 fr. 88 ft' solid rock
Jeremy Thompson it. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. >
3430 Amity Hill Rd, Statesville ft. ft. ..
Physical Address,City,and Zip ft. ft. N O V I b (U 14
iredell 4751 69 7793 21.REMARKS
County Parcel Identification No.(PIN) C.`` ''..._2:y
56.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.C cation: I'
35 714089 80 829593 }� (�, ( � -
CHI
N W it �� l .2./4
6.Is(are)the well(s)ix Permanent or Temporary Signature of Certified Well ntractor Date /
By signing this form,I hereby cerify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or [X No with 15A NCACO2C.0100 or 154 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 backof 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 I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:265 (it.) 24a. For All Well: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdeerent(example-3iP00'and 2(100) constmctionto the following: ,
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rota above,also submit one copy of this;form within 30 days of completion of well
12.Well construction method: rY construction to the following: C
(i.e.auger,rotary,cable,direct push,etc.)
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm)6 Method of test:weir 24e.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 12 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22.2016
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