GW1-2022-00908_Well Construction - GW1_20220107

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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 260 fr• 305 It. 35�
ft. ft
NC Well Contractor Certification Number
is.OUTER CASING for multi-cased wells OR LINER if a livable
Rowan Well Drilling FROM TO DIAMETER THICKNESS M1IATERIAL
Company Name 0 fL 49 f6 1 6114 In' SDR21 PVC
328121 16.INNER CASING OR TusnvG eotherwal closed-fool!)
2.Well Construction Permit#: FROM TO DL1117ETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Counly,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water icultural �MunicipaUPublic ft, ft Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agr is
01rrigation
Geothermal(Heating/Cooling Supply) tt)Residential Water Supply(single) ft. ft. inIndustrial/Commercial Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 @. Z0 ft. Holeplug Gravity 8
Monitoring ' •Recovery ft. iL
injection Well:
fL ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK ifalivableFROM TO :MATERIAL EMPLACEMENT METHOD
Aquifer Test �Storrawater Drainage R• N•
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM I To DESCRIPTION color,hardness soilIroek type,grain sae,etc.
0 It. 14 I'L Clay t Sand
4.Date Well(s)Completed: 12/22/21 Well 11I#328121 14 ft. 39 ft.
Weathered Rock
5a.Well Location: „ ft. 49 ft. Solid Rock
Cornerstone III Properties ft. +t• i-�E: _7F,
P i
Facility/Owner Name Facility IDA(ifapplicable) ft. ft.
102 Aaron Way, Salisbury 28144 rL ft. AN _
Physical Address,City,and Zip ft. ft.
Rowan 321 F004 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 43 0.649 N 80 28 32.626
6.Is(are)the well(s)ff)Permanent or Temporary Signature of Certified Well Contractor Date
/iy signing this farm,/hereby cert�that the well(s)u•as(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E)No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If'this is a repair,Jill out brown well construction itJomnation and explain the nature ofthe copy of this record has been pro rided to the well owner.
repair under A21 remarks section or on the back oJ'dris 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 GWA 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 (B•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nndtiple wells list aN depths ifdt1ferent(example-3 a 100'and 1 a 100') construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"4617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12. Rotary above,also submit one copy of this!form within 30 days of completion of well
(i.e.Well construction method:.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm).3.5 Method of test: Weir 24c. For Water Sunnily&Infection Wells: In addition to sending the form to
ch the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: lorine Amount: 14 oz completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016