GW1-2022-09370_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Spencer Adams 14.WATER-ZONES
Well Contractor Name FROM TO DESCRIPTION
505 ft• 540 ft. sum
4449 A
R. ft.
NC Well Contractor Certification Number 15.OUTER CASING`for multi-cas ed wells,UR LINER if e" Gcable
Rowan Well Drilling TER THICKNESS MATERIAL
OFROM ft. 3O fL 61/4E in• SUR21 PVC
Company Name - i
16.INNER CASING OR i UBING eotheraiatclosed-loo
2.Well Construction Permit#: 380159 FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. tt. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft• ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
fL ft ia.
:)Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
'Irrigation FROM TO - MATERIAL EMPLACEMENT DtETHOD&AMOUNT
Non-Water Supply Weil: o R• 20 R• Holeplug Gravity 12bags
Monitoring DRecovery ft. ft.
Injection Well:
:)Aquifer Recharge .Groundwater Remediation R• ft.
19.SAND/GRAVEL PACK if a' livable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Storruwater Drainage h• ft.
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG'attacb additional sbeets3f necessa -
Geothermal(HeatingtCooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION co►or,hardness,soatrock bW,grain size ere
L, 0 tt. 15 ft. Clay
4.Date Well(s)Completed.9/2 /22 Well ID#380159 15 ft. 37 ft, solid rock
Sit.Well Location: H• tr' i G j ` y �,d
Angela Miller fL fL
Facility/Owner Name Facility IDtl(ifapplicable)
t3. rt
1180 Jackson Rd, Salisbury 28146 ft• ft
Physical Address,City,and Zip ft. ft.
Rowan 420 059 21 RENIARKs . .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertiT[Cation:
35 34 4.788 N 80 27 45.272
6.h(are)the well(s)fflPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordmrce
7.Is this a repair to an existing well: Oyes or JRNo with 15A NCAC 02C.0100 or i5A NCAC 02C.0200 lVell Construction Standards and that a
If this is a repair,fill out known well construction information and explain Cite nature of the copy of this record has been provided to the well owner.
repair under 421 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-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: 540 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths+f different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) 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 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,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) 30 Method of test- Aids t 24c.For Water Suonly&Iniection 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: 25 oz completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016