GW1-2021-01914_Well Construction - GW1_20211001

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-01914
Are you submitting a printed form?* r Yes
f•No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Rowan Well Drilling [e-mail]
Is this a revision to the form you have previously submitted?
r Yes F No
WELL CONSTRUCTION INFORMATION
.............................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4449 A SPENCER ADAMS ROWAN WELL DRILLING
2.Well Construction Permit#:
198868
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
9/28/2021 198868 30
(gallons per minute)"

5.Well Location
Facility/Owner Name
Sam Fowler Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Rowan 126 009
Physical Address* Street Address
1830 E NC 152 Hwy
Address Line 2
City State/Province/Region
China Grove NC
Postal/ZZp Code Country
28023 United States
Latitude* 35.3356720000 Longitude't0.3292640000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
245 surface?
Formultiplewells Iistall depths if different 176
(example-3 a200'and 2@100') in feet
11. Borehole diameter:
10.Static water level below top of casing:(ft.) 6
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
30 13a. Method of test:
If applicable Weir
13b. Disinfection type:* 13b.Amount:*
chlorine 14 oz
14.WATER BEARING/FRACTURE ZONES

From To Description
180 205
in feet in feet
205 245 20 GPM
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 6.25 sdr21 pvc
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 holeplug gravity
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 25.00 clay
in feet in feet
25.00 100.00 sandy overburden
in feet in feet
100.00 166.00 weathered rock
in feet in feet
166.00 176.00 solid rock
in feet in feet
180.00 185.00 dirty vein
in feet in feet
215.00 223.00 dirty vein
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only

CERTIFICATION INFORMATION
...............................................................................................................................................................
*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
qawmt aw�?W 6
Signature of Certified Well Contractor
Submittal Date 10/1/2021