GW1--08016_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-11 For Internal Use,Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Nam` 575 ft- 590 ft- 12 GPM
4449A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If cap !foible)
Rowan Well Drilling FROM TO • DIAMETER ; THICKNESS MATERIAL
q2H 0 ft' 95 ft- 61/4 ::in- SDR21 PVC
CompanyName 16.INNER CASING OR TUBING(eeothermalclosed-loop)
400`t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction penults(I.e.VIC County,Stale,Variance.eta) ft t ft. • in.
3.Well Use(check well use): R. ` ft. in.
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Water Supply Well: FROMC E TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural °Municipal/Public 0 ft. ',.ft. in.•
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) •ft. IR. In.'
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
hrigation FROM TO r MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 Holeplug Gravity 17 bags
onitoring °Recovery f6 ` r.
Injection Weil: •
ft. ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(lf applicable) .
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO : MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage D' i ft. •
Experimental Technology °Subsidence Control ft. i ft. ,
Geothermal(Closed Loop) °Tracer a DRILLING LOG(attach additional Steels If necearaiy)
FROM TO DFSCRIPTION(color,6Waw,wll/reelttypy gran dre,etc.)
Geothermal(Hating/Cooling Return) Other(explain under#21 Remarks) 0 e. 20 Red Clay
4.Date Well(s)Completed:l 128123 WanD0 400428 20 70 fL Sandy Overburden
5a.Well Locatlon: 70 ft. 85 Weathered Rock
Roger Phillips 85 fe. 95 ft. Solid Rock
Facility/Owner Name Faciltym#(ifepplicable) 95 120 R Tan/softer rock ;� -
280 St Matthews Church Rd, Salisbury ft ` f +' `.`'t•`�i; ti'4'''--.li-¢-)
Physical Address,City,and Zip ft • ; ft. U E C 1 /. ZO[3
Rowan 510 028 21.REMARKS` •
^F � ,, !
i
County Parcel Identification No.(PIN) G�1i(:,,4„ -� /10
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweU field,one tatflong is sufficient) 22.Certification:'
35 35 5.051 N 80 20 6.646 W L , li12 '123
Signature of Certified Well Contractor Date
6.Libre)the well(a)C3Permanent or °Temporary
By signing this form,I hereby cer7fy that the well(s)war(xrre)constructed in accordance
7.Is this a repair to an existing well: ®Yes or x°No with 15A NCAC 02C-0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out blown well construction information and explain the nature ofthe con,-of this record has been provided to'the nell owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTALNUMBER ofwells construction details. You may also attach additional pages if necessary.
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drilled:1 SUBMITTAL'INSTRUCTIONS
9.Total well depth below land surface:605 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dfffereast(example-3@200'and 2(I00) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifame,level it above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (M) 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: constriction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources, Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)12 Method of test:Weir 24c.For Water Supply&Injection 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: 1.75 lbs completion of well construction to the county health department of the county
where constructed.
Form 0W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised2.22-2016