GW1--06950_Well Construction - GW1_20241118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
4449-A 74 fA 160 ft• 2 GPM I
240 ft• 300 ft. 2 GPM 1 1
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER Of op Ucable)
Rowan Well Drilling FROM TO DIAMETER , THICKNESS MATERIAL
0 ft• 74 ft. 61/4 IP. SDR21 PVC
Company Name WELL 240926 04 16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit#: _ FROM TO - DIAMETER THICKNESS MATERIAL
List all applicable wellconstructionpermits(i.e.UIC,County,State,Variance.eta) ft. ft. . tn.
3.Well Use(check well use): ft. & in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipavPublic 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft, ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18:GROUT.. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Holeplug Gravity
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery c3Satinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft• ft. i.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary).
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DFscR>rnoxcWtor,iwansss aotu, rt grain aim etc.)
4.Date Well(s)Completed:10/3124 WellID#24092604 12 ft• 50 1t. Sandy Overburden
5a.Well Location: 50 ft* 69 ft. Weathered Rock
Fit Properties LLC 69 f. 74 ft. Solid Rock
Facility/Owner Name Facility ID#(if applicable) 74 ft• 140 ft• Very soft gray rock
3935 Acre Rd, Maiden 28650 ft• ft. i-f FF l—^ �r� -S ' i
Physical Address,City,and Zip ft. ft.
n <.,'
Catawba 365713233677 21.REMARKS :... .. . .NOV• 3 S "G L4
County Parcel identification No.(PIN)
Sb.Latitude and longitude In .r `r.,.• 1 ngldegrees/minutes/seconds or decimal degrees: �;�.,.��r.3
Orwell field,one tat/long is sufficient) 2 Certification:
35 34 54.424 N 81 10 39.993 W 1 a /3 j2)(
6.Is(are)the weU(a)Jx Permanent or OTemporary Sign of Certified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No with ISA NCAC 02C.0100 or ISA NCAC.02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well conduction 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 I 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: 305 (it) 24a.For All Wells: Submit this'foam within.30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2 c@t 100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If muter level is above casing,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: Rotary
(ie.auger,rotary,cable,direct push,etc.) construction to the following: f I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test:weir 24c.For Water Supply&Infection Wells: In addition to sending the form to
chlorine 14 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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