GW1-2021-04675_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: r^+
Spencer Adams _ 14.WATER ZONES
=ft- 325
DESCRIPTION
Well Contractor Name 2O G�
4449A ��A� 1 L ft- 7 GPM
U,, 4 GPM
NC Well Contractor CertiticationNumber r,rr, rSlh
15.Rowan Well Drilling i91��;1;:�s'vB+�r,f�Y;�r1 FROM OUTER C CASING formD TER OR LINERifa IiMATERIAL
g u. 0 ft 123 It- 1 6 1/4 in.
SDR21 JPVC
Company Name ����
16.INNER CASING OR TUBING eotherroal closed-Too
2.Well Construction Permit#: 15 FROM I TO I DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) H• IL
in.
3.Well Use(check well use): ft. R. in.
17.SCREEN
Water Su Well:
Supply FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)MunicipaMblic 0 It. ft. in.
. Geothermal(Heating/Cooting Supply) )Residential Water Supply(single) g. ft
lndustriaUCommercial [)Residential Water Supply(shared) 1&GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Holeplug Gravity 21 bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [)Groundwater Remediation
19.SAND/GRAVEL PACK Cif applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control 1f• ft.
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) i :Other(ex lain under#21 Remarks) I FROM TO DESCRIPTION color,hardness,soWrock mtn size,etc.
0 lt- 12 ft. Clay
4.Date Wel)(s)Completed:4/20/21 well ID#2651 15 12 ft 75 eft. Sand, Overburden
5a.Well Location: 75 ft. 113 ft, Weathered Rock
Joshua Brooks 113 ft- 123 ft- Solid Rock
Facility/Owner Name Facility TD#(if applicable) ft. ft.
325 Brandon Cole Dr, Salisbury28147 ft. ft.
Physical Address.City,and Zip ft. ft.
Rowan 270 128 21.REMARKS
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 43 0.516 N 80 37 58.476 W J,,� Y 17 D 12 t
6.ls(are)the well(s)oPermanent or [)Temporary Signature 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: [)Yes or ONo with 15A A'CAC 02C.0100 or 1 SA NCAC 02C.0100 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 record has been provided to the well owner.
repair under#21 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 I 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: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,#'erent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:25 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 276994617
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) 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 fort within 30 days of
Chlorine 15 oZ completion of well constriction to the coup health department of the
136.Disinfection type: Amount: P I county P county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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