GW1-2021-04648_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Spencer Adams 14.WATER ZONES k
,s� FROM TO DESCRIPTION
Well Contractor Name �a ^Q�'1 100 fL 165 ft- 24 GPM
4449A �( 7 Lft. ft. j
NC Well Contractor Certification Number � �
ry(.ff' S 15.OUTER CASING for multi<ased wells OR LINER if a licable
Rowan Well Drilling 1S,>011n �u '1 J e��Qn FROM TO DIAMETER THICKNESS MATERIAL
=met 0 rt 63 rt 6 1/4 in SDR 21 JPVC
Company Name
354600 16:INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaVPublic 0 ft. FL in.
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft. n• in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
—)Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 rt• Holeplug Gravity 18 bags
:)Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL, EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft rt•
f Experimental TechnologySubsidence Control ft. ft.
Geothermal(Closed Loop) DTmcer 20.DRILLING LOG attach additional sheets if necessary)
k Geothermal (Heating/Cooling Retum rl Other(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardaeu,solurock type,grain size,etc.
0 ft- 15 ft- Red Clay
4.Date Well(s)Completed:4I14/21 Well ID#354600 15 ft- 45 rt Sand Overburden
5a.Well Location: 45 rt• 63 rt• Solid Rock
Tommy Small
Facility/Owner Name Facility ID#(ifapplicable)
170 Stoney Knob Ln, Salisbury28147 it. ft.
Physical Address,City,and Zip ft. ft.
Rowan 316 003 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one IaUbng is sufficient) 22.Certification:
35 42 57.335 N 80 35 30.537 W ��
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6.Is(are)the well(s)OPermanent or OTemporary 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: OYes or E)No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known is-ell construction 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 W-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdoerent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft•) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+" 1617 Mail Service tenter,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Iniection Wells: 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
12.Well construction method: construction 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
13a.Yield(gpm)24 Method of test:weir 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:Chlorine Amount: 12 OZ completion of well construction'Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
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