GW1--08019_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: _' ;Print qrm:::.
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES j ,
Well Contractor Name FROM. TO i DESCRIPTION
4449-A 160 ft: 190 ft. 4 GPM
NC Well Contractor Certification Number 550 575 1i GPNI
15.OUTER CASING(for multkased wellsLOR LINER(ifs ncabte)
Rowan Well Drilling FROM TO DIAMETER .em MATERIAL
ATERIAL
Company Name 0 ft 90 ft. 161/4 In. SDR21 lPVC -
383549 16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(le,UIC County,&ate,Variance,etc.) ft. ft. I In.
3.Well Use(cheekwell use): ft. ft. I in.
Water.Supply Well: - 17.SCREEN
.. -Agdcultutal E]MtmicipallPubliC FROM TO I DIAMETER' SLOT sunTHlctavESS MATERIAL
0 ft. • ft in.
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) ft. .;n is
Industrial/Commercial E3Residential Water Supply(shared)
Irrigation FROM
GROUT .
FROM TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 0: 20', ft. Holeplug Gravity 8 bags
Monitoring 10Recovery ft. ft
Injection Well: '
uifer Recharge QGroundwaterRemediaticm ft. D'
tmifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) .
FROM TO MATERIAL, :EMFLACEMENTMEIHOD
Aquifer Test QStormwater Drainage it ' ft. i'
Experimental Technology !Subsidence Control ft. , ft. ',
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional:sheets ff necessary).
Geothermal(Heating/Cooling Return) ("Other(explain under#21Remarks) FROM TO DESCRIPTION(color,bardnsa,sowwektype grain aka'etc.)
11/16/23 383549 0 20` � clay I ''4.Date Well(s)Completed: Well ID# 20 e, 60 , D. Sandy,Overburden
Sa.well Location: 60 80 is Weathered Rock
Georgellen Goss 80 ft- 90 ft- Solid Rock
Facility/Owner Name Facility ll)#(if applicable). 140 ft, 160• fr. Brown Rock/Soft a... __
0 E Ridge Rd, Salisbury 28144 370 ft 400 ft. Brown Rock r
Physic Address,City,and Zip ft. "+3"�, '� In
r al •
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Rowan 322 002 21.REMARKS
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes//seconds or decimal degrees: I n i�o T a:!3 n:':30;:: :: �'S
(ifwell field,on let/loagissufEcient) 22. ertiflcatione ,`�"��
35 43 38.823 N 80 27 6.746 w
6.Is(are)the well(s)€%Permanent or Temporary �gnatuic o ed Well Con 1 Date
By signing this form I hereby certj that the wells)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or x No with ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If thisis a repair,fall out brown well construction information and explain the nature of the copy ofthis record has been provided to the'well owner,
repair tinder 1121 remarks section or on the back ofthisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to'provide additional well site details or well
construction,only I 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:585 (IL) j
For multiple wells list all depths ijdifferent(example-3@200'and 2@100) 24a Far Ail Weltsd S»bmit this fair within 30 days of completion of well
construction to the following:
10.Stadc water level below top of casing: (ft.) Division of Water Resources,Information ProcessingUnit;Ijwnter level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1 7
IL Borehole diameter:6 (hi.) 24b.For Injection Wells: In addition to sending the form to the address in 7Aa
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
Division ofWater Resources,
FOR WATER SUPPLY WELLS ONLY: iceenter g Injection 9-1t36 Program,
1636.Mall Service Center,Raleigh,NC 27699-1636
15 weir
13a.Yield(gpm) Method of test: 24c.For Water Suably&Injection Wells: In addition to sending the form to
chlorine 1.7 lbs the addss(es) abovg, also submit one•copy of this form within 30 days. of
13b..Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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