GW1-2022-01796_Well Construction - GW1_20220214

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
100 ft• 725 fr.
4449-A
175 fL 245 fL scar.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a ficable
Rowan Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
0 ft 91 ft. 61/4 1 In' I SDR21 PVC
Company Name
367477 16.INNER CASING OR TUBING(geothermal dosed-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.(IIC County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) It. ft. ;n
:—Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
i 1ni ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Holeplug Gravity 24 bags
_;Monitoring DRecovery ft. ft.
Injection Well:
ft ft
J Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [J Salinity Barrier FROM TO I MATERIAL, EMPLACEMENT METHOD
J Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if recess
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillroek type,grain size,etc
0 ft. 20 ft Clay
4.Date Well(s)Completed: 1/12/22 Well ID#367477 20 ft 60 ft Sandy Overburden
5a.Well Location: fi0 ft 91 ft weathered Rode
Elvira Carrillo 81 ft. 91 ft Solid Rork
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
125 Ted Lane, Salisbury 28146 ft ft
Physical Address,City,and Zip ft. ft
Rowan 411A044 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.C rtificad Ind�PI1pCtil UM
35 36 0.533 N 80 29 51.681 `,1,
6.ts(are)the well(s)oPermanent or EJ 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: [3Yes or JqNo 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: 245 (ft.) 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: 00 Division of Water Resources,Information Processing Unit,
Ifwaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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) 12 Method of test, Airlift 24c.For Water Supply&Iniection 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: 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