GW1-2021-07975_Well Construction - GW1_20211122

s Print Formm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A
123 fL 165 fL ,G-
165 fL 305 fL 'Gvu
NC Well Contractor Certification Number 15:OUTER'CASING;for.midti-cisdd,"veils pl>- ER Wa``licable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 fL 122 fL 61/4 tn' SDR21 PVC
Company Name
306772 16>INNER'CASING'ORTUBING geothermal�losed-loop)
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
2.t �:' -_
Water Supply Well: 17-SCREEN_ ' .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural MunicipaVPublic fL ft in
_ Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) fL ft. in.
IndustriaVCommercial Residential Water Supply(shared) 18:'GROUT
1 irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Holeplug Gravity 27 bags
Monitoring Recovery ft. fL
Injection Well:
ft. fL
1 Aquifer Recharge Groundwater Remediation `19.SAND/GRAVEL"PACK"if a``h'c'able
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD a
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20-I)RiLLiNG LOG attach idditioiisl sheets:ifaecessa _
FROM ft. TO
fL DESCRIPTION color,hardness soill _
' .Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) rock $rain etc.
ay
4.Date Wells Completed: 10/6/21 Well ID#306772 15 fL 70 fL
sandy overburden
5a.Well Location: 76 ft. 112 ft' weathered rock
Mark Riley 112 ft- 122 ft- solid rock
Facility/Owner Name Facility iD#(if applicable) 123 ft• t65 ft• fragile rock
375 Blue Heron Rd, Salisbury 28146 fL ft. t"
Physical Address,City,and Zip ft. ft. 1 I 1
Rowan 611 153 21 REMARKS �V
County Parcel Identification No.(PIN) M1I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IVEE RMATION PROCESSING UNF
(ifwell field,one lat(long is sufficient) 22.Certification:
35. 40 2.809 N 80 20 22.525 W
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified well Contractor Date
By signing this farm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No 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 well owner.
repair under 921 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 if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (fL) 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,
Ifwater 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Airlft 24c.For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection type: Chlorine Amount: 14 oz
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016