GW1-2021-04642_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
$ encer Adams a 1�4 14.WATER ZONES
p 63,�..• M FROM TO DESCRIPTION
Well Contractor Name
4449A ���AY 17 2021 165 ft 205 h 3 GPM R
5 ft 285 f- 4 GPM
NC Well Contractor Certification Number rs r0�n �;l r�` 15'.OUTER CASING for multi cased wells OR LINER if a livable
Rowan Well Drilling it ,Il.. ,;°�'£� �,•„�I FROM To DIAMETER THICKNESS MATERIAL
`' 0 95 6 1/4 in. SDR 21 JPVC
Company Name
304152 16.INNER CASING OR TUIIING eotherroal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.67C,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
L Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft ft in.
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
_ 1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 n Holeplug Gravity 38 bags
Monitoring (—Recovery ft. ft.
Injection Well:
ft ft.
r'Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVELPACK if applicable
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test Q Stormwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrack type,grain size,etc
0 ft. 15 ft- Clay
4.Date Well(s)Completed:4/30/21 well ID#304152 15 rt- 75 It- Sand 'overburden
5a.Well Location: 75 fL 85 k• Weathered Rock
Maria Garcia 85 ft 95 h- Solid Rock
Facility/Owner Name Facility ID#(if applicable) ft. ft.
207 Cindy Rd, Salisbury 28147 115 rt 135 1L Dirty Rock/Vein
Physical Address,City,and Zip ft. ft
Rowan 476 B 117 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavlong is sufficient) 22.Certification:
35 37 9.068 N 80 34 15.488 W
6.Is(are)the well(s)OPermanent or Temporary SigDatkre 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: DYes or 'ONO with 1 SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Iflhis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this farm.
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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (f>) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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 rasing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6
(�m.
) 24b.For Infection Wells: 1n 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.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)7 Method of test:Airlift 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: 15 oZ completion of well construction to4lic county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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