GW1-2022-10259_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams `.14:WATEWZONES
FROM TO DESCRIPTION
Well Contractor Name
90 ft. 305 ft• rrz cPn+ -
4449-A ft. ft.
ifliGf4lia:tD:1l'f3^..30w: UI'iri
NC Well Contractor Certification-Number {15..OITI'ER CASING for:multi=cased=well's;OR LIN le
Rowan Well Drilling FRONT TO DIAMETER THICKNESS MATERIAL
0 ft. 79 ft. 6114 in SDR21 PVC
Company Name -
16:"INNER-CASING.OR.TUBING' eottiermal dosed-too
2.Well Construction Permit#:357334 FRONT TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. io•
3.Well Use(check well use):
Water !'Y Supply Well: 17 SCREEN, ,.
P FROM TO, DIAMETER SLOT SIZE THICKNESS DIATEILIAL,
Agricultural 13Municipal/Public ft. ft. in•
Geothermal(Heating/Cooling Supply) XIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
iS.GROUT. -
'Irrigation FROM TO NIATERrat. DIPLACENIENT NIETHOD&ANIOUNT
Non-Water Supply Well: 0 ft- 20 K• Hoteplu9 Gravity6.
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
190 SAND/GRAVEL PACK-if a"`Ii[a61e'
Aquifer Storage and Recovery DSalinity Barrier FRONT To MATERIAL EMPLACEMENT dfETHOD
Aquifer Test oStormvtater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
_,Geothermal(ClosedLoop) Tracer 20DRILLINGLOG attactiadditionatsheetsifnecesss'
_ Geother FRONT TO DESCRIPTION color,hardness,soilfrock rain size etc
mal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) 0 ft, 7 ft. clay
4.Date Well(s)Completed: 10/07/22 Well ID#357334 7 ft. 50 ft. Sandy Overburden
5a.Well Location: ft. 69 ft. weathered Rock
Dick Palmore 69 ft- 79 ft, Solid Rock
Facility/Owner Name Facility ID#(if applicable) % ft.
1045 River Trace Lane, Salisbury 28144 ft. ft•
ft. ft.
Physical Address,City,and Zip 7.
Rowan 307C272 21:REDIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(if wellfield,one lattlong is sufficient) 22.Certification:
35 45 3.476 N 80 28 11.072 W p ` j.�z✓
6.Is(are)the well(s)IBPermanent or [3Temporafy
Signature of CertifiltWell Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X)No with 15A NCAC 02C.0100 or ISA NCAC 02C.0100{yell 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 tire well owner.
repair under#21 remarks section or on the back of thisform. 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: 405 00 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths Tf 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 ureter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.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 IDjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 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
13b.Disinfection type: chlorine Amount: 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 2-22-201.6