GW1-2022-08454_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTON
4449-A 56 ft- 65 ft.
Y3GPM
NC Well Contractor Certification Number 190 ft. 225 ft.
15.OUTER CASING formulti,cased wells OR LINER if a lieeble
Rowan Well Drilling FROM TO DIAMETER THICKNESS aATERIAL
Company Name 0 ft• q3 ft. 61/4 1° SDR21 PVC
360585 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit ft: fr
DIADIriTER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(J1C,Carruy.Slate,Variance,etc.) ft. in.
3.Well Use(check well use): ft.
V►'ater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESSIII MATERIAL
__.
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
IndustriaVCommercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 56 bags
`Monitoring DRecovery ft. ft.
Injection Well:
ff. (t.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable).
(- Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i- AquifcrTest E[Stomm'aterDrainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach'additionAl sheets if necessary
i
FROM TO DESCRIPTION color,hardness,soitkock e, rain sae,etc.Geothermal(Heating/Cooling Retum) -� Other(explain under#21 Remarks)
0 fL 12 ft, red clay
4.Date Wells Completed: 7/15/22 Well ID#360585 12 ft. 27 ft,
()Com P sandy overburden
5a.Well Location: 27 ft. 43 ft. sorid rock
Trallen Homes Construct ft. ft.
Facility/Owner Name Facility 1134(if applicable) ft. ft. s;,'•• �_
1080 Castle Mill Lane, Salisbury 28147 ft. ft. _ r.—', > s-•-5 �` Mr
Physical Address,City,and Zip ft. ft. AUG r 2 Q 20Z2
Rowan 201030 21.REMARKS.. u v
County Parcel Identification No.(PIN) fflivi'riia 3llPi` -.P,.Pui-,rg Unii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if Drell field,one lat/long is sufficient) 22.Certification;
35 38 38.469 N 80 37 14.468 W
6.Is(are)the well(s)E)Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,J hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or IX;No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
Ifthis is a repair•fill out knower well construction information and explain file nature of the copy of this record has been provided to the well mvner.
repair under 1121 remarks section or mu 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-I 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: 225 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 _200'and 2@100') construction t0 the following:
10.Static water level below to of casing: 8
p g: (ft.) Division of Water Resources,Information Processing Unit;
Iftivarer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IJ.Borehole diameter: 6 (in.) 24b.For Iniection 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,ete.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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
136.Disinfection type: chlorine Amount: 11 oz completion of well construction to the county health department of the county
where constructed.
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016