GW1-2021-04668_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Spencer Adams v y 14.WATER ZONES
?.�-•�Well Contractor Name FROM TO DESCRIPTION
4449A PN�A`l 17 2p2t 165 fL 205 ft. 3 GPM
5 ft- 285 ft- 4 GPM
NC Well Contractor Certification Number t'�'I'� 15.OUTER CASING for mWti�ased wells OR LINER if a livable
Rowan Well Drilling Ji1 G111 ` 1, :� CY'0P FROM TO DIAMETER THICKNESS MATERIAL.
ut� 0 It 95 ft• 61/4 i° I SDR21 JPVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
304152
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f_. Agricultural QMunicipal/Public 0 IL ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in.
Industrial/Commercial QResidential Water Supply(shared) yg.GROUT
lrrl atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt• Holeplug Gravity 38 bags
Monitoring p Recovery
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater 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 QSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary)
ex lain under#21 Remarks FROM To DESCRIPTION color hardn soiltrock rain s ere
Geothermal(Heating/Cooling Return) Other( )
0 ft- 15 ft- Clay 1
4.Date Well(s)Completed:4/30/21 well ID#304152 15 ft 75 ft. Sand overburden
5a.Well Location: 75 tt 85 it" Weathered Rock
Maria Garcia 85 ft 95 it- Solid Rock
Facility/Owner Name Facility ID#(if applicable) ft. ft.
207 Cindy Rd, Salisbury 28147 115"' 135 ft- Dirty Rock/Vein
Physical Address,City,and Zip ft. fL
Rowan 476 B 117 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
dwell field,one latllon is sufficient
C g ) 22.Certification: ;
35 37 9.068 N 80 34 15.488 W
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6.Is(are)the well(s)oPermanent or Temporary Signa re ofCertified 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: OYes or ONO with 15A NCAC 02C.0100 or 15A 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 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 M-) 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 1@100) construction to the following:
10.Static water level below top of casing: (fL) 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 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
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13a.Yield(gpm)7 Method of test:Airlift 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 15 oz completion of well construction to;the coup health department of the
136.Disinfection type: Amount: P � ry eP county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016