GW1-2021-04672_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams °�
'�"A v� '� FROM
WATER ZONES
ROM11 TO - DESCRIPTION
well Contractor Name
4449A ^Ot11 100 ft 165 ft• 24GPM
p p p 11 L L
v�1N� ft. ft. I I
NC Well Contractor Certification Number r,sc�(t�
r)tc ,0 15.OUTER CASING fotmuttf<esed wells OR LINER i[a licable _
Rowan Well Drilling -� �I c�^x�:Di FROM TO DIAMETER THICKNESS MATERIAL
1" ^.` ` 0 n 63 tt 6 1/4 in SDR 21 PVC
Company Name �� 00
16:INNER CASING OR TUBING eothermal closed-loop).
2.Well Construction Permit#' FROM I TO DIAMETER THICKNESS MATERIAL
w List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): rt ft. in.
17.SCREEN
Water Su Well:Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
-.Agricultural QMunicipal/Public 0 ft ft. in.
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft R• in.
lndustrial/CommercW DResidential Water Supply(shared) 18.GROUT
"Ilffigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n• 20 ft• Holeplug Gravity 18 bags
Monitoring DRecovery ft. "ft.
Injection Well:
tt ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft.
Experimental Technology DSubsidence Control ft ft.
HGeothermal(Closed Loop) - QTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCooling Return - Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnen,soivrock bTw,grain size,etc.
0 ft 15 ft- Red!Clay
4.Date Well(s)Completed:4/14/21 well ID#354600 15 rt• 45 IL Sandy Overburden
5a.Well Location: 45 ft 63 rt• Solid Rock
Tommy Small " ft-
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
170 Stoney Knob Ln, Salisburys28147 ft ft.
Physical Address,City,and Zip ft ft.
Rowan 316 003 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/atinutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 42 57.335 80 35 30.537 /
N W t-( I
6.Is(are)the well(s)OPermanent or OTemporary Signatufe 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 eidsting well: OYes or EX 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 Hell 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 ifnecessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (ft) 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,
!f water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection 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 Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
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
Chlorine 12 oZ completion of well construction to the coup health department of the county
13b.Disinfection type: Amount: P county P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016