GW1-2022-03165_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 72 ft 305 ft corn
335 f6 405 ft ]GRA
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a Gcable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 72 ft- 6114 ' tn' I SDR21 PVC
362153 J M B2401 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaVPublic ft, ft, is
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
IndustnaUCommercial Residential Water Supply(shared) 18.GROUT
111rrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft- 72 ft EZ Seal Pump 8
Monitoring Recovery 0 ft 3 ft. Holeplug Gravity 8
Injection Well:
ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
J Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
--I Aquifer Test DStormwater Drainage ft ft
-1 Experimental Technology EJ Subsidence Control ft fL
_ Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets ifnecess
_-J Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillmek type,grain s' etc.
0 ft 42 ft Sandy Overburden
4.Date Well(s)Completed:2/2(22 Well EN 362153 42 ft 72 ft Solid Rock
5a.Well Location: ft ft
William Thompson ft ft.
Facility/Owner Name Facility ID#(if applicable) it ft.
1065 Raymond Meadows Rd, Salisbury 28146 ft ft
Physical Address,City,and Zip ft fL 7 2022
Rowan 420cO85 21.REMARKS
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
r rNaKtam, gl7rJ11
(if well field,one lat/long is sufficient) 22.Certification:
35 34 3.126 N 80 28 30.006 W
z J� C zZ
6.Is(are)the well(s) xj Permanent or OTemporary Signature dfCertified 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 IgNo 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: 405 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iiidii ferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: (fL) 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) 3 Method of test: weir 24c.For Water Supply Ar Injection Wells: In addition to sending the form to
the address(es) above, also submit lone 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