GW1-2022-01797_Well Construction - GW1_20220214

Pflnt WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Form
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 92 ft- 425
fr. fr.
NC Well Contractor Certification Number 15.OUTER CASING fbr multi-cased wells OR LINER if a usable
Rowan Well Drilling FROM TO DIAMETER THICKINESS MATERIAL
Company Name
0 fL 9T ft. 6114 is Galvanized
364558 Ili.INNER CASING OR TUBING eotbermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate.Variance,etc.) ft. ft.
is
3.Well Use(check well use): fr• ft
in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single)
fr. f4 is
Industrial/Commercial Residential Water Supply(shared) I&GROUT
—)Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 21 ft. Hoteplug Gravity 14 bags
Monitoring Recovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if ne"ss
Geothermal(Heating(Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock bpe,grain sae,etc
0 It. 9 ft. Gay
4.Date Wells Completed: 1/11/22 Well IDt1364558 9 ft. 82 ft. ,. n
()Com P WeaMeretl Granite �f
Sa.Well Location: u ft. 92 It. Solid Rods
Carol Satterwhite fl. ft. FEB Il
Facility/Owner Name Facility iDll(if applicable) ft. ft. Unit
1150 Old HWY 70, Salisbury 28147 fr. fL pyspp
Physical Address,City,and Zip ft. ft.
Rowan 827 003 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35 43 29.808 N 80 37 21.275 W l t
6.b(are)the well(s)MX Permanent or OTemporary SignatHre of Certified well Contractor Data
By signing this form,1 hereby certo that the ivell(s)was(were)constructed in accordance
7.is this a repair to an existing Welk []Yes or X®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knovn well construction information and explain the nature of the copy of this record has been provided to the well oivner.
repair under 421 remarks section or on the back of this farm
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: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple trells list all depths ifdoerent(example-3 tt 00'and 2C100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
Iftrater 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 thislform 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) 2.5 Method of test: Weir 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: 22 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