GW1-2021-08002_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Name tw 3 ft-FROM DFSCRIPT70Y
18 GPM
4449A
ft. fL
NC Well Contractor Certification Number (� 1&OUTER CASING for mutti-cased.wells OR LINER if a We
Rowan Well Drilling P�� �� FROM To DIAMETER THIMMs MATERIAL
:'V 0 11 6 R• 6141a• SDR21 PVC
Company Name 322024 ��rfl� de 16.INNER CASING OR TUBING(geothermal closed lob
2.Well Construction Permit# r.vs�� O\•�` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable:veil construction permits(ie.UIC, aunty,State,Variance,etc.) R R. 1n.
3.Well.Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS NATERIAL
Agricultural E)MunicipaWublic 0 ft. R, in.
Geothermal(Heating/Cooling Supply) 1MResidential Water Supply(single) R. R. in
Industrial/Commercial DResidential Water Supply(shared) is,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT MMOD&AMOUNT
Non-Water Supply Well: R R• Holeplug Gravity 5 bags
Monitoring Recovery R. ft.
Injection Well:
R
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage R R.
Experimental Technology []Subsidence Control ft tL
Geothermal(Closed Loop) 0Ttacer 20.DRILLING LOG attach additional sheets If neeessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM To DESCRIPTION color nerao sootsoctc a �
18 ft- ay an
4.Date Well(s)Completed: 6/28/21 wen 1D#322024 R- 50 R• Sandy Overburden
Sa.Well Location: 50 R. ` ft. Weathered Rock
Jamie Grant R R Solid Rock-
Facility/Owner Name Facility 1D#(ifapplicable) R, ft.
4780 Sherriils Ford Rd, Salisbury 28147 ft. .
Physical Address,City,and Zip R. (L
Rowan 456004 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 41 34.659 80 34 9.868
N W
6.Ls(are)the well(s)EX Permanent or Temporary 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: [)Yes or [MNo with 15A NCAC 02C 0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known we construction information and explain the nature of the ropy 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
construe on,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 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple welll list all depths iftli erent(example-3@200'and 2@1M construction to the following:
8
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
It.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16M
13a.Yield Wm) 18 Method of test: Airlift 24c.For Water Supply&Iniecdon Wells: In addition to sending the form to
Chlorine 18 oZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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