GW1-2021-07978_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER,ZONES.A
Well Contractor Name FROM TO DESCRIPTION
4449-A 63 fL 205 fL ,-x crra
345 fL 365 fL stair
NC Well Contractor Certification Number '15:OUTER CASING for.multi4ased wells OR LINER if a `licible
Rowan Well Drilling FROM TO DIAMETER' THICKNESS MATERIAL
0 fL 63 fL 61/4 m' SDR21 PVC
Company Name
233218 16.`14NERCASING OR TusING edther'mal closed-loop)
2.Well Construction Permit#: FROM I TO I 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): i+' ff' in.
Water Supply Well: -.17.SCREEN =
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
]Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X)Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT . f
i Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Holeplug Gravity 16 bags
:—)Monitoring Recovery ft. fL
Injection Well:
fL ft.
Aquifer Recharge Groundwater Remediation
'19.SAND/GRAVELPACK`if a Uieabli
_;IlAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 1•20.DRILLING LOG.itt ich additionel'sheets if iecessa
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soi0,oek type,grain size,etc.
0 fL 18 ft, day
4.Date Well(s)Completed:9/30/21 Well ID#233218 18 fL 53 ft' sandy overburden _
Sa.Well Location: 53 ft' 83 ft' solid rock
Madison Homes f4 ft. �t�����_ �_ N
Facility/Owner Name Facility ID#(if applicable) ft. ft.
0 Patterson Rd, Salisbury 28147 ft. ft. V 2 2 2@
Physical Address,City,and Zip ft. ft -�I tl JpJ PF, F� i
Rowan 207 005 21:REMARKS
u �/ �x u%vri Jr:r
County Parcel Identification No.(PIN) fit!PROCESSING UNIT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertification
35 37 49.322 N 8037 1.514 W ,.) 170
6.Is(are)the well(s)oX Permanent or IDTemporary 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: E]Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis is a repair,fill out known well construction information and explain the nature ofthe 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 i GW-I 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: 365 00 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 levels below top of easing: (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 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) 8 Method of test: Weir 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 16 oz 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