GW1-2022-06492_Well Construction - GW1_20220603

I
z Print Form
s
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams ra<WATERZONES i
Well Contractor Name FROM TO DESCRIPTION
112 ft 225 fL ow
4449-A
225 it. 285 fL ak w
NC Well Contractor Certification Number 15:OU1ER"CASR!iG toimulticaaedawclls OR.LIIVER ifa bte
Rowan Well Drilling FROM TO DIA11fETER TH<CtovEss MATERIAL
0 112 fL 1 61/4 SDR21 PVC
Company Name
357296 ':1CRGWERCASWQQRTMl[N eabe�rareloudted ;>> .
2.Well Construction Permit#: FROM TO DIAMETER TIUCI04M MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) fL ft in.
3.Well Use(check well use): ft ft in
,41 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICENESS I MATERIAL
Agricultural DMunicipal(Public R fL in.
Geothermal(Heating/Cooling Supply) x©Residential Water Supply(single) tL ffi ib
hldustnal/Commercial ®Residential Water Supply(shared) itt.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No Supply Well: 0 20 it. Fiaepiup Gravity
Monitoring Recovery ft. &
Injection Well:
fL ft
Aquifer Recharge ®Groundwater Remediation ]9:,SAiD/GRA C'PACK(if a"' 'tile777777
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test E3Stonmwater Drainage R' fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tmcer ;ZO::DItII IdNG I UG.iHicb ufklitioml sLeeta if Mt .
FROM TO DESCRIPTION color, eoilfroek eta
Geothermal eatin ooling Return) 00ther lain under#21 Remarks 0 it. 13 fL Gay
4.Date Well(s)Completed:5/4/22 Well ID#357296 13 fL 12 ft Sandy Overburden
5a.Well Location: az ft 102 & wea Bred rock
Cornerstone 3 Properties 102 fL IV & Sid rock
Facility/Owner Name Facility M#(if applicable) fL iL
6395 Providence Ch Rd, Salisbury
tG R -
Physical Address,City,and Zip R ft. J U N 0 2022
Rowan 621 007 z1:REt►fARlcs ''"
County Parcel Identification ation No.(PIN) 1,. LC I 11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ii i Uf\I
(if well field,one lat/long is sufficient) 21 Certification:
35 37 58.216 802144.391
a
NW -t—
I
6.b(am)the well(s)Ox Permanent or ®Temporary Signature of Certified wets Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.is this a repair to nn existing well: QYes 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 known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 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 i 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: 285 (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtff'erent(example-3Qa 200'and 2@100) 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 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:
(Le.auger,rotary,cable,direct push.etc.)
E
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Weir 24c.For Water SDDDIv&Injection 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: 20 oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016