GW1--06899_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: Print`Fom ' `'
1.Well Contractor Information: •
I
George Brown ]o:waTER ZONES
Well Contractor Name I I
FROM TO DESCRIPTION
4654-A 88 m 365 ft, 1/2 GPM
NC Well Contractor Certification Number ft ft. i
15.OUTER CASING(for multl-cased yells)OR LINER(if aP licable)Rowan Well Drilling FROM TO DIAMETER TIUCKNEBS MATERIAL
Company Name 0 ft.
88 16 1/4 b. I sdr21 PVC
2023 16033 16:INNER CASING OR TUBING(geothermal dosed-loop).2.Well Construction Permit#: FROM TO I DIAMETER 1 THICKNESS MATERIAL
List all applicable well contintction permits(Le.UIC,County,State,Variance,etc.) ft. ft. , in.
3.Well Use(check well use): fa ft. In.
Water Supply Well: 17.SCREEN
A CIlItO[al FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
D gn f[�Municipal/Public 0 ft• in.
DGeothennal(Heating/Cooling Supply) XDResidential Water Supply(single) ft. f` in.
Dlndustriat/Commercial DResidential Water Supply(shared)
Dlrrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
°Non-Water Supply Well: 0 ft• 20 ft• holeplug gravity 9 bags
Monitoring DRecovery ft. R:
Injection Well:
jAquifer Recharge DGroundwaterRemediation & ft.
DAquifer Storage and Recovery [Salinity Barrier 19.S /GRAVEL PACK Of applicable)
EOM TO MATERIAL
DAquifer Test DStoanwater Drainage ft. ft. EMPLAcnreNTMETHon
DExperimental Technology DSubsidence Control ft. ft.
DGeothetmal(Closed Loop) .DTmcer
20:DRU!J:ING LOG(attach additional sheets if neeesnry)':...
DGeothenml(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM To DEscRIPnoN(color,hardness soil/rock type,wain day etc.),
10/2/24 202316033 0 n' 70 ft• dirt/brown rock
4.Date Well(s)Completed:
Well no 70 R• 88 ft• solid rock
Sa.Well Location: ft. ft.
Aly Lindsey ft. ft.
Facility/Owner Name • }'acilitylD#(if applicable) ft. ft.
112 Lindsey Ridge Lane, Statesville ft. ft. . '
Physical Address,City,and Zip ft. ft. r�U V 2024 Iredell 4723 12 1851 21•REMARKS
County Parcel identification No.(PIN) if"" :�
Sb.Latitude and longitude in d .
g egress/minotes/seco°ds or decimal degrees;
(if well field,one lat/long is sufficient).
35 44 50.529 N 80 57 3.729 22.Ce tio°°
w . l0lz lz1
6.Is(are)the well(s)OPermanent or [Temporary rg�ture of C ed well Contractor Date
By signing this farm,I hereby motif,that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: Dyes or XDNO with 1SA NCAC 02C.0100 or 1SA 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'iwll owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
• 8.For Geoprohe/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
• 505 SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface:
For multiple wells list all depths ifdifferent(example-3(d200'and 2Qa 100) ons c
For All Wells: Submit this form:within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water
If inter level is above casing,use•'t" Resources,Information Processing Unit,1617 Mail Service Center,,Raleigh,NC 27699-1617
11.Borehole diameter:6 Om) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well coasfr°etion method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 type: Method of test:Weir 24c.For Water So
the ��&Infection Wells: In addition to sending the form to
13b.Disinfecttoachlorine 23 oz address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Form GWd North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016