GW1--03329_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 49 ft- 300 ft. I GPM
360 ft. 380 ft. a GPM
NC Well Contractor Certification Number '15,OUTER CASING for multi=cased wells OR LINER if a "Gcable
Rowan Well Drilling FROM To DIAMETER THICKINESS MATERIAL
0 ft. 49 ft. 6114 ' in' SDR21 PVC
Company Name
216.INNER CASING OR TUBING' "eothermal closed-oo
2.Well Construction Permit#: NA FROM To DIAMETER THICKNESS MATERIAL `
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well• 17.SCREEN': . . . .
FROM TO DIAIIIETER SLOT SIZE THICKNESS MATERIAL
x JAgricultural E]Municipal/Public ft. 8, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g• ft. in.
IndustriaUCommercial Residential Water Supply(shared)
18.GROUT„
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 9
Monitoring Recovery ft. fa
Injection Well:
ft. ft.
Aquifer Recharge [_Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
— Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test IDSton'nwater Drainage
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
RFROM TO DESCRIPTION color,hardness,soiVrock in siz etc.
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks) 0 ft. 1e ft- Clay
4/12/23 NA ft. ft.
4.Date Well(s)Completed: Well ID# 18 39 Sandy overburden
58.Well Location: ,g ft. 49 ft. Solid Rock
Coleman Phifer 92 ft. 100 ft* Brown vein
Facility/Owner Name Facility ID#(if applicable)
ft. ft
2023
2955 Woodleaf Rd, Salisbury ft. ft. 2
it. ft. Infcsr-;_1`';ai1 Pr:!'*7'xzr l.rr:1 Physical Address,City,and Zip 3
Rowan NA 21'.REMARKS =:
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.Certification:
35 42 21.883 N 80 31 28.046 W
L- 1121z3
6.Is(are)the well(s) [X Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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#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 1 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: 425 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ti dierent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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) 4 Method of test: Weir 24c.For Water Sunoly&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: 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 Revised 2-22-2016
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