GW1-2021-04678_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
Spencer Adams _ a yI 14.WATER ZONES
� .y, .� FROM TO DESCRIPTION
4449AWeIlContractarName •tea,,,,,\\�'1•'�''3 120 ft 205 tt 2GPA
7 385 425 A
`
2�Z1 !c. tr. 3GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Ucable
Rowan Well Drilling �; �r�zrslr��L)t�1 FROM TO DIAMETER twcKNEss MATFdtIAL
i~ "^'�t — 0 ft. 47 rt• 6 1/4 in• I SDR 21 JPVC
Company Name y V '��-
355638 FROM
INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THLLCKNESS MATERIAL
List all applicable well construction permits(i.e.WC,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.
Agricultural OMunicipal/Public ft. ft. in.
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
lrri ation ]FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 21 rt• Holeplug Gravity 22 bags
:)Monitoring ` Recovery ft. ft.
Injection Well:
ft. R.
Aquifer Recharge QGroundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. it.
Experimental Technology Dsubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Return) rJOther(ex lain under#21 Remarks FROM TO DESCRIPTION color,hardness,safl/mck m st etc.
0 ft- 15 ft- Red ,Clay
4.Date Well(s)Completed:4/27/21 WellID#355638 15 fL 37 eft, sandy Overburden
5a.Well Location: 37 ft* 47 ft, Solid Rock
Trent Stephens ff. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
235 Talley Ln, Salisbury 28146 . ft. ft.
Physical Address,City,and Zip ft. ft.
Rowan 424039 21.REMARKS
County Parcel identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22 Certification:
35 33 4 N 8031 18 W
6.Is(are)the well(s)E)Permanent or OTemporary Signature fff Certified Well Contractor Date
By signing this form,I hereby certify that the rrell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or lNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 hell oxwer.
repair under#2I remarls section or an 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 if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (rt•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@200'and 2@1001 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
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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)5 Method of test:Airlift 24c.For Water Supply&.Iniection Wells: In addition to sending the form to
Chlorine 18 OZ the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction io 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
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