GW1-2021-01704_Well Construction - GW1_20210323

This form can be used for single or multiple wells
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
mom TO DESCRIPTION
Well Counselor Name 125 ft. 175 R. 4GPM
4449A 185 k. 245 k. 7 GPM
NC Well Contractor Certification Number IS.OUTER CASING for muti-cued l welh OR LINER if• ip I
Rowan Well Drilling FROM lY DIAMETER tRICK fE55 MATER AL
0 ft. 23 fr. I 61/4 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING thermal cimed4on
332318 FROM TO DIAMETER TxIC]O Ess MATERIAL
2.Well Construction Permit#: R. R. in.
List all applicable well permits p.e.(:ounty,Same,Variance,Injeclivn,etc.)
n. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To I DIAMETER I SWTSIZE I THICKNESS MATERIAL
[]Agricultural E)Municipal/Public rt. R. I in.
DGeothermid(Heating/Cooling Supply) []Residential Water Supply(single) k. (L in,
❑lndustrial/Commercial DResidential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPIACEMENTMEIHOOd AMOUN7
Dlrri 'on 0 R. 21 k. Holeplug Gravity 10 bags
Non-Water Supply Well:
DMonitoring ❑Recovery
It, I n.
Injection Well: R, I R.
DAquifer Recharge OGroundwater Remediation 19.SANDIGRAVEL PACK(if applicable)
DAquifer Storage and Recovery OSslinity Barrier FROM I To I MATERIAL I EMPI.ACEMNT METHOD
DAquifer Test DStomi water Drainage
k.
❑Experimental Technology []Subsidence Control ft.
20.DRILLING LOG aft It nd lidond sbeeb if necessary)
[]Geothermal(Closed Loop) DTraCer FROM TO DESC: TION fork,,hainuier,mW.k me eaulauto,ew)
[]Geothermal(HeafinglCooling Realm DOther(explain under#21 Remarks) 0 R. 8 n. Clay
2/2/2021 332318 a k. 245 a Solid Rock
4.Date Well(s)Completed: Well ID# n h
So.Well Location:
Mikel Gubanez
R. h
Facility/Owa n Name Facility ID!!(if applicable)
120 Oslo Ln, Salisbury 281463 021
n, k.
Prh•{�sicai Address,City,and Zip MAp rowan 422 231 21.REMARKS
County Parcel Identification No.(PM)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifweil field,one let/long is sufficient)
35 33 41.149 N 80 29 44.019
Signature of Certified Well Contractor Dace
6.Is(arc)the well(s): 21sermaoent or []Temporary By signing day form. I hereby cent that the well(s)was(were)constructed in aecvalance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well C'onsnactiou Slandarda and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy ofthas record has been provided ao the well owner.
If Ihr,is a repair,fill out known well construction information and erpla/a the nature of the
repair under-11 remarks rernort or rm the bark vfth,,firm. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-wafer supply walls ONLY wah the.same consvncdon.you can
subma one form. 245 SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: (R.) 249. For All Wells: Submit this form within 30 days of completion of well
Fornvdriplewell,list allati ifdr(ferent(erample-3 2004and2@ltW) construction to the following:
10.Static water level below top of easing: (ft.) Division of W tier Resources,Information Processing Unit,
//wmer levee is shove caring.uee 1617:Nail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:�6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
1'lUtQ 24a above, also submit a copy of this fo within 30 days of completion of well
12.Well construction method: ry form within
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
11 13a.field(gpm) Method of test: Weir 24c.For Water Supply&Injection Wells:
Chlorine 12 OZ Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.