GW1-2021-07976_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams ',.'14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 185 ft- 245 ft.
tcvr
305 ft. 325 fL 3G—
NC Well Contractor Certification Number -I& , ble),
-OUTER CASING#6r�!Llt d welb), fica DIAMETER
OR
11p
Rowan Well Drilling FROM To TE, MATERIAL
0 ft96 ft- 61/4 '- I SDR 21 ]Pvc
Company Name
J16ANNER CASING OR IN T G(aecitherinad closed4od p):� -1,
2.Well Construction Permit#: 363671 FROM TO DIAMETER THICKNESS 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.
A
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
JAgricultural 0Municipall'Public ft. ft. in.
—)Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) —ft ft ire
industrial/commercial [3Residential Water Supply(shared) JKGROUT�'
7,,IlrTigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT—
Non-Water Supply Well: 0 ft- 20 ft Holeplug Gravity 12 bags
:]Monitoring C)Recovery ft. ft.
Injection Well: ft ft.
:JI)Aquifer Recharge IDGroundwater Remediation �=fq.,SAND/GRAVF'L,PACK(if Iilicable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:-)Aquifer Test OStormwater Drainage ft. ft.
:]Experimental Technology OSubsidence Control ft ft.
lGeothermal(Closed Loop) 13Tracer •z20.DRILLING LOG(attach additional sheds if necessary)-.,
nGeothermal(Heating/Cooling Return) rJ Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardnfts,soilf ak type,grytin size,etc) I
0 ft. 15 fL clay
4.Date Well(s)Completed: 10/1/21 Well ID#363671 15 ft. 58 ft. clay/sand
5a.Well Location: W ft. 86 ft' sand/weathered rock
Dianne Pruitt 86 ft. 96 ft* solid rock
Facility/Owner Name Facility ID#(if applicable) ft. ft. NOV 2 2
580 Harris Rd, Salisbury 28147 ft. ft.
Physical Address,City,and Zip ft. ft. DWR SECTION
2E"REMARKS�_,,1,
Rowan 463046 111CODOATION,020CESSINIG UN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwefl field,one lavlong is sufficient) 22.Certification:
35 39 14.821 80 32 40.292 W
6.Is(are)the well(s)oPermanent or OTemporary 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: E]Yes or )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#21 remarks section or on the back oJ'1hisJ&rm. 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I 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 itdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
lfwater 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
13a.Yield(gpm) 5 Method of test: weir 24c. For Water Suimly&Infection Wells: In addition to sending the form to
chlorine Amount: 15 oz the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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