GW1-2021-04643_Well Construction - GW1_20210514

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
e
1.Well Contractor Information:
Spencer Adams , 14.WATER ZONES
� �4s, •-- FROM TODE.SCRIPTION
Well Contractor Name 2�
4449A L 170 ft- 185 ft- 3 GPM
Cd�Q� e 60 n- 285 ft- 12 GPM
NC Well Contractor Certification Number r? nr oziS%. �g 15.OUTER CASING for multi-cased wells OR LINER if n licable
Rowan Well Drilling it �t�i la'� .,� Cl FROM ft. To DIAAniTER in. THICKNESS MATERIAL
0 132 6 1/4 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop) -
2.Well Construction Permit#•350659 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable nell construction permits(i.e.UIC,County,State,Variance,elc.) fL tt. in.
3.Well Use(check well use): 1 ft.
Water Supply Well: `17.:SCREEN
PP Y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 0 ft. ft. is
Geothermal(Heating(Cooling Supply) Residential Water Supply Ingle) ft. ft.
Industrial/Commercial E)Residential Water Supply ared) 18.GROUT
Trri g ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT _
Non-Water Supply Well: 0 ft. 20 ft• Hole lug Gravity 20 bags
Monitoring Recovery ft. R•
Injection Well: ft. ft.
Aquifer Recharge nGroundwater Remediation 19.SAND/GRAVEL PACK if a iicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATF.RiA.L EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology ElSubsidence Control i ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG fattaschadditionah;sheets if necessa .:.
FROM TO DESCRIPTION color,hardaeM sairlrock n s etc.
Geothermal(Heating/Cooling Return) Other lain under#21 Remarks) 0 ft. 15 ft. Red Clay
4.Date Wen(s)Completed:4/8/21 Well ID#350659 15 it• 100 ft• Sand' Overburden
Sa.Well Location: 100 ft. 122 ft- Weathered Rock
Chris Hannold 122 ft• 132 ft- Solid Rock
Facility/Owner Name Facility ID#(if applicablej 140 n- 145 n- Dirty Vein
805 Peach Orchard Rd, Salisbury 28147 175 fL 185 tf Dirty vein/water
Physical Address,City,and Zip I ft. ft.
Rowan 407 112 21 REiKARIcs
I
County Parcel Identification No.( IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal de Tees.
(if well field,one laUlong is sufficient) 22.Certification:
35 3710.621 80 30 44.141 N -
i ;
6.Is(are)the well(s)i%Permanent or Temporary f
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or X�No 1 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known we11 construction information and explain the nalure of the SPY of this record has been provided to the well owner,
repair under#21 remarks section or on the back of this form. Le
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the 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:285 i (It-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3Q200'and 2Q100') ; construction to the following:
10.Static water level below top of casing: i (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 Injection 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: j 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test:Airlift 24c.For Water Suonly&Iniection�Wells: In addition to sending the form to
i
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type.Chloride Amount: 15 oZ completion of well construction to" the county health department of the county
where constructed.
Form GW-I North Carolina Department o Environmental Quality-Division of Water Resources Revised 2-22-2016