GW1--03836_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATM ZONF4
Well Contractor Naine FROM TO DESCRIPTION-1
4449-A 49 ft. 300 ft. t c.rrr
380 ft. 380 ft. 3 GPb1
NC Well Contractor CsdificationNumber 15.OUTER CASING formulti�rrsed w811s OR LINER ifa Hcable
Rowan Well Drilling FROM TO. DIAItfETER THICKNESS MATERIAL
0 ft. 49 ft. 6114 in. SOR21 PVC
CampanyName 16.INNER CASING OR TUBING eotbermaI dosed-loatil
2.Well Construction Permit#: NA FROM I DIAMETER THICKNESS 3Ls,TERIAL
List all applicable well construction permits(i.e.UIC,County,State,Madame,etc.) ft. tt. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS 511TERUL
x Agricultural ®Municipal/PubGc ft.
Geothermal(Heating(Cooling Supply) )Residential Water Suppfy(single) tY. ft. in,
htdustrialiCornmercial 13Residential Water Supply(shared) I&GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Hotep{ug Gravity s'
Monitoring Recovery ft. ft.
Injection Well:
fr. ft.
Aquifer Recharge Groundwater Remediation
19.SAIV'DlGRAVEL PACK(if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stomlwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) .Tracer 20,DRILLING tM attach additional sbeets ifnecesse
Geothermal(Heating/Cooling Return) Other(explain under 021 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock typp.grain size,tic.
0 ft. is ft, Clay
4.Date Well(s)Completed:4/12123 Well ID#NA 1e ft. 39 ft. Sandy Overburden
5a.Well Location: 39 ft. 49 ft. Solid Rock rq e
Coleman Phifer 82 ft. 10o rt. eroxn vein `�,�r !a.
LJ
Facility/Owner Name Facility IDS(if applicable) ft. ft. i
2955 Woodleaf Rd, Salisbury ft. ft.
Physical Address,City,and Zip ft. ft. y pf9tii L`i1 Pt. SibQl^9
xl:xEnTARKs
Rowan NA :
County Parcel IdentifrcationNo.(PIN)
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35 42 21.883 N 80 31 28.046
6.Is(are)the well(s)Ox Permanent or Temporary Signature of Certified Well Contractor Date
By_• :accordance
7.Is this a repair to an existing well: [3Yes or QNo rvitl ds mud that a
If this Is a repair,fill out brown well construction Information and explain the nature of the .cop
repair wider'rll remarksseetion ormr rite hack of"rhlsfnnn. 23.
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same lro ails or well
construction,only 1 GVir 1 is needed. Indicate TOTAL NUMBER of wells Co
drilled:' SU
9.Total well depth,below land surface: 425 (ft-) 24 ion of well
For nrtiltiple n•ells list alidepths rf different(exareple-3@200'mid 21r 100) 0o
A �
10.Static water level below top of casing:35 (ft.) 't,
If aster level is above casing.
-11.Borehole diameter: 6 (in.) 24 ress in 24a
Rotary ab ion of well
12.Well construction method. co
(i.e.auger,.rotary,cable,direct push,etc.)
rogram,
FOR WATER SUPPLY WELLS ONLY:
13s.Yield(gpm) 4 Method of test:Weir 24 the form to
tile 30 days of
13b.Disinfection type: Chlorine Amount: 20 oz cot the county
wh
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016