GW1-2021-04638_Well Construction - GW1_20210514

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Print Form-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ;
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1.Well Contractor Information:
Spencer Adams 7
r �27, f��) 14.WATER ZONES i
,� y_- FROM TO DESCRIPTION
Well Contractor Name iTz), ,� y 4449A 120 ft. 205 ft- 2 GPM
202•�
NC Well Contractor Certification 385 R. 425 R• 3 GPM
cation Number ��� 15.OUTER CASING for multi-cased wells OR LINER if a licable
Rowan Well Drilling p; ', afoc'S1C):11)t�11 FROM TO DIAMETER THICKNESS MATERIAL
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rr:.,h �, ,,.t?. — 0 ft 47 ft. 6 1/4 in. SDR 21 PVC
Company Name [}' d '��-
3 C C G�O 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: 556 O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UJC,County,State-Variance,etc.) R. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSI7E THICKNESS MATERIAL,
Agricultural ElMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
lhi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 21 fL Holeplug Gravity 22 bags
Monitoring ' Recovery
injection Well:
Aquifer Recharge OGroundwater Remediation
_ 19.SAND/GRAVEL PACK if applicabte
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
f Aquifer Test E)Stormwater Drainage ft. ft.
i Experimental Technology DSubsidence Control
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin CoOIiR Return) r3Other(explain under#21 Remarks FROM TO DFSCR PTIOx color,harda sotltmck rasa size,etc.
0 ft- 15 ft- Red,Clay
4.Date Well(s)Completed:4/27/21 Weil ID#355638 15 ft. 37 °tt• San6k Overburden
5a.Well Location: 37 f, 47 ft, Solid Rock
Trent Stephens ft. ft.
FacilitylOwner Name Facility ID#(if applicable) ft. ft.
235 Talley Ln, Salisbury 28146 ft.
Physical Address,City,and Zip ft, ft.
Rowan 424039 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 33 4 N 8031 18 W
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6.Is(are)the weil(s)JgPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or )No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this retard has been provided to the well owner.
repair under#21 remarks section or on the back of this form. i
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:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(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,
If water level is above casing,use'•+" 1617 Mail Service Center,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)5 Method of test:Ai111ft 24c.For Water Supply&.Iniection Wells: In addition to sending the form to
Chlorine 18 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc G Revised 2-22-2016
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