GW1-2022-06493_Well Construction - GW1_20220603

j �nrit Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Spencer Adams 1,VWATERZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 205 fL 245 fLM GG
1L fL ,
NC Well Contractor Certification Number &,OUfER'CASINO fontnultltaseda&ells URIINER.ifq' Me -j,
Rowan Well Drilling FROMTO DATER UECENM MATERNAL
0 R 1 108 fL 1 61/4 'm I SDR21 PVC
Company Name
362624 '16 INNER-CM1NG `AR�nM]Nc fottierviat cloyed loo z
2.Well Construction Permit#: FROM TO DIAMETER TLHCIWFSS MATERUL
List all applicable well construction permits(7.e.UIC County,State,Variance,etc.) R it. 1 in.
3.Well Use(check well use): & % im
Water Supply Well: FROM
SCREEN , ..•
FROM TO DIAMETER 'SLOT SITE,. .TI11clor SS 'MATERNAL A r
Agricultural ® UPu Municipablic R & in.
Geothermal(Heating/Cooling Supply) 131tesidential Water Supply(single) ft ft, in.
Industrial/Commercial 13Residential Water Supply(shared) It GROUT,-
Irrigation FROM TO MATERM V EMPLACEMENT METHOD&AMOUNT..
Non-Water Supply Weil: 0 R 20 & Horeptug cranky
Monitoring Recovery ft. ft.
Injection Well: & &
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL-PACK a"' file coy
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage fL fL
Experimental Technology Subsidence Control & fir.
Geothermal(Closed Loop) E37rracer -20.>13RHAINGLAOG"atttKh=dditiooa dheeb"t[oecee -
FROM TO DESCREMON color, soillmik s' etc..,.,
Geothermal(Heating/CoolingReturn) Other( lain under#21 Remarks 0 R 10 S Clay i
4.Date Well(s)Completed:5/4/22 Well lD#362624 10 % 98 & Sandy overburden
5a.Well Location: B6 R' 108 ft Solid Rotic
Cornerstone 3 Properties fr. ft
Facility/Owner Name Facility ID#(if applicable) R R
4960 Long Ferry Rd, Salisbury 28146 & ft.
Physical Address,City,and zip tti ft. JUN o 3 ?o7?
Rowan 606 067 21: mARxs n°= i3
County Parcel Identification No.(PIN) y" i�}i�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laWong is sufficient) 21 Certification:
35 40 23.800 N 80 20 17.695 a,
6.Is(are)the well(s)OPermanent or 13Temporary Sigoarure of Cftfied well Contractor Date
By signing this form,I hereby certo that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or X®No with ISA 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 norm 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 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: 245 00 24s. For All Wells: Submit this:'form within 30 days of completion of well
For multiple wells list all depths tfdtfferent(example-3@100'and 2@100) construction to the following:
10.Static water level below top of casing: (M) Division of Water Resomws,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:
(ie.auger,rotary,cable,direct push ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 6 Method of test:Weir 24c.For Water SunDly&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: 12 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 Revised 2-22-2016
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