GW1-2022-00914_Well Construction - GW1_20220107

s, Print Form''
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES-
Well Contractor Name FROM TO DESCRIPTION
112 ft 365 ft. 1 GM
4449-A
ft ft
NC Well Contractor Certification Number 15.OUTER CASING.for TM!_)ased wells "OR LINER if a "licable
Rowan Well Drilling FROM TO DIAMETER THICKNESS "' MATERIAL
0 ft 112 ft 6114 1O' SDR21 PVC
Company Name
360315 16:'INIVER CASING`OR Tu)31NG eotliermal clditea-too �•' _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft ft in•
Industrial/Commercial DResidential Water Supply(shared) 18 GROUT
Irrl ation FROM TO ' MATERIAL f EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft Holeplug Gravity
Monitoring DRecovery ft. ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation 1g.SAND/GRAVEUPACK ifa licable. .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_'.Aquifer Test Stormwater Drainage f IL
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer �10.:DRILLING LOG,.attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/o k rain s etc.
0 ft. 20 ft Clay
12/15/21 360315 ft ft
4.Date Well(s)Completed: Well ID# 20 1o2 Sandy Overburden
5a.Well Location: 10 ft 112 ft. Solid Rock
Alison Naito ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
350 Waccamaw Dr, Salisbury 28146
ft ft
Physical Address,City,and Zip ft ft 7
Rowan 360315 21.REMARKS' <.
County Parcel Identification No.(PIN) i it
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 42 54.579 N 80 20 20.194 N
I Its- (2-1
6.Is(are)the well(s)�IX Permanent 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: []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#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
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: 365 (N-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00') construction to the following:
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
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: 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: 17°Z 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