GW1-2021-04674_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
1.Well Contractor Information: '"°
Spencer Adams �!�. J — 14.WATER ZONES !.
Well Contractor Name r FROM TO DESCRIPTION
4449A `VhAy I I TO 200 n 245 ft- 7GPM
�� UV111 ft. ft.
NC Well Contractor Certification Number f ��j�K JCn„a,rr 15.OUTER CASING for multi-cased wells OR LINER If a lieable
Rowan Well Drilling ,9i1.�r,"; YSd�"t ZV�� PROM TO ft. DWNE'IERin THICKNESS MATERIAL
6r 0 75 6 1/4 SDR 21 PVC
Company Name
3 rJ/1��� 76.INNER CASING OR TUB WG eothermai dosed-loop)
2.Well Construction Permit#: 54 FROM I TO I DIAMETER THCKNESS I MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
17:SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural - QMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
1-1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 if" Holeplug Gravity 13 bags
Monitoring 1311ccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
.__ Aquifer Storage and Recovery QSalinity Barrier,., FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage >t. ft.
Experimental Technology I0Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) . FROM1 To DESCRIPTION color hardoen,soillrock tyM givin sIM cte.
0 ft. 15 eft; Red Clay
4.Date Well(s)Completed:4/19/21 Well m#354325 15 fL 40 ft- Sand'y Overburden
5a.Well Location: 40 rt' 65 fL Weathered Rock
Don McGee 65 ft- 75 ft- Solid Rock
Facility/Owner Name Facility lD#'(ifapplieable) fL ft.
585 Goodnight Rd, Salisbury 28147 fL ft.
Physical Address,City,and Zip fL ft.
Rowan 768065 21.REMARK
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 39 33.379 N 80 35 39.101 W �` ,�-.. `�I i°� lza
6.Is(are)the well(s)@)Permanent or Temporary SignaturJ of Certified Well Contractor Date
By signing this form,I hereby certify that the w•ilis)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or [ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full out known well 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 ofthis 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:1 SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: 245 (ft•) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple we0s list all depths ifdiffereni(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
ll.Borehole diameter:6 (in.) 24b.For lniection 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)7 Method of test:Airlift _ 24c•For Water Supply&Infection Wells: In addition to sending the form to
Chlorine 14 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources. Revised 2-22-2016