GW1-2021-04647_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: a
1.Well Contractor Information:
Spencer Adams ..,� 7'' 14:WATER ZONES
Well Contractor Name #y ,�` FROMI TO I DESCRIPTION
4449A ��1AY ,� 2021 50 ft 145 ft• 3 GPM
200 ft 245 ft' 7 GPM
NC Well Contractor Certification Number a ci U6Zl1M 15.OUTER CASIN for multi-cased wells OR LINER if a ncable
Rowan Well Drilling �� `� FROM TO DIAMETER THICKNESS MATERIAL
l,' r..Y or
0 ft. 46 ft• 6 1/8 SDR21 PVC
Company Name 354601
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I IttATF.R1AL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) ft. k in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17..SCREEN._.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Pubfic 0 ft. ft. ia.
Geothermal(Heating/Cooling Supply) X)Residential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
—1hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• Holeplug Gravity 40 bags
Monitoring . Recovery ft. ' ft.
Injection Well:
Aquifer Recharge Groundwater Remediation [ft.19.SANDD/GRAVEL PACK tfa Ilceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft•
Experimental Technology Subsidence Control
Geothermal(Closed Loop) JDTracer 20.DRE LLING LOG attach additionidsbeetsifnecessaryl
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardo sotl1mck type,gmtn sla eta
0 ft. 35 rr. Clay ;
a.Date Well(s)completes:4/12/21 Wel]ID#354601 35 It- 46 ` It. Soli8 Rock
5a.Well Location: ft. ft.
Brent Smith ft. ft.
Facility/OwnerName Facility IDN(ifapplicable) ft. ft.
4885 Stokes Ferry Rd, Salisbury 28146 ft.
Physical Address,City,and Zip ft. ft.
Rowan 618 078 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 37 18.023 80 24 27.955
'1� 'A —1
6.Is(are)the well(s)o Permanent or Temporary Signatule of Certified Well Contractor; Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ®X No with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under N21 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8erent(example-3@200'and 2QI00� construction to the following: i
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use`+ 1617 Mail Serviee01Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in-) 24b.For Injection Weill: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of'this form within 30 days of completion of well
]2.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources l,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
I
13s.Yield(gpm) 10 Method of test-Airlift 24c.For Water Supply&Iniection 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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