GW1-2022-04484_Well Construction - GW1_20220509

Priht Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14 WATER zorlss ,.
Well Contractor Name FROM TO DE4CRn QN
4449-A 90 fL 345 S 2aw, f
345 8. 705 R now k
NC Well Contractor Certification Number 13 OtMM CA51NG.fns:mtdd�etled:iv6nt:Olt f[dt!iFdt if 61e
Rowan Well Drilling FROM To DIAMETER mucw4m MAWAUL
CompmyName 0 80 6114 Ile SDR21 PVC
363297 r~n�vER cAswc oR Tosn�rc eleaed ton
2.Well Construction Permit M. mom To mA TER TFUCKWI-M MATERLU
IJst all applicable xr ll consvwciion permitr i7 a UIC Cormry,State,Variance etc) IL R in.
3.Well Use(check well use): R fL to
IN,
ater Supply Well: t i:SCREENI :;-;
FROM TO DIAMb9'F.R SLOTSITE lrm
Agricultural QMtnticipaMblic fL R to
Geothermal(Heatinecoo(mg Supply) Residential Water Supply(single) u
IndustrialiCommeteial OResidential Water supply(shared) 1tt GROV1
Irrigation FROM TO MATERIAL EaQLACEMENT MEM010 a:AMOUxr
n--Water supply well: 0 fL 20 & hdapty cra,ety 15 caps
Monitoring Recovery fL ft
j n We : ft �Aquifer Recharge Groundwater Remediation
A uifer S e and Recove Salini Barrier q Storage Recovery a tY FROM. TO MATERUL I EMPLACBMEIVT METHOD
Aquifer Test C)Stormwater Drainage tL a
Experimental Technology OSubsidence Control R. ft.
Geothermal(Closed Loop) 13Ttatxr RI DGLING'1AG ut�e5s�itiooilaLtietitt
Geothermal eatin Cooi' Rum Other(-plain undet#21 Remarks FROM ro DFseRRrTlox eotor u,Nrxt ere
0 R 10 B Clay
4.Date Wea(s)Completed:4/12122 Well 1 Dli 363297. 10 a 80 & sw*o
Se,.Well Loattfon:
w & & Sam resit
Devendedeet Singh Dange w &
Faeilityiowner Name Facility lD#(ifepplicable) R R f^
205 Stone Ridge Dr,Salisbury 28147
ft MAYPhysical Address,City,and Zip fL0 202
Rowan 064C181 Z1 R>=1KnRiKs
County Parcel Identification No.MN)
Sb.Latitude and longitude in degreestmintttes/seconds or decimal degrees:
(ifweli field,one lavlovig is sufficient) 2L Certification:
35 38 0.220 N 80 28 15.788 qr
6.h(are)the weil(s)OPermanent or Temporary Signature Certified wen Contractor Date
By signing this jam I hereby certify that the wed(s)was(were)constructed in accordance
7.Is this a repair to an existing well: aYes or EjNo with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
ifthis is a repair,fill out brown well construction information and esplaln the nature afdre copy 4�hir+retard has been provided to the well owner.
repair under 921 remarks section or on the back ofthis farm 23-Site diagram or additional well details:
S.For ceoprobe/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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 (t) 249, For All Wells Submit this forth within 30 days of completion of well
For multiple nwas list all depths fili,jferent(example-3@200'and 2@100) COttSIIUdIOn to the following
10.Static water level below top of casing: 0L) Division of Water Resources,Information Processing Unit,
Ijwater level is above acing,use"+" 1617 Mall Service Center,Raleigh,NC27699-1617
il.Borehole diameter:s (in,) 24b.For Injection, 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.
(Le.auger,rotary,cable,duect push.etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigb,NC 27699-16M
13a.Yield(gpm) 5 Method of test:weir 2&For Water Saonly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131L Disinfection type: Chlorine Amount. 2 ft completion of well construction to the county health department of the county
where constructed.
I,
Form ow-1 North Carolina Department of Favivanmental Quality-Division of Water Resources Revised 2-22-2016
I