GW1--00354_Well Construction - GW1_20240112

Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES 1 '
We1lContractor Name FROM TO DESCRIPTION
4449-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 44 ft. 61/4 i • SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
397920
2.Well Construction Permit#:39 19 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIG County,State,Variance,etc.) ff. ft. , in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: - 19.SCREEN •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
R Agricultural ijMunicipal/Public 0 ft. ft. In.;
R Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) R ft. in.
•Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Holeplug Gravity 35
R Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
I Aquifer Recharge DGrotmdwater Remediation
19.SAND/GRAVEL PACK(if applicable)
1 Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
•Aquifer Test DStormwater Drainage ft. ft. ,
R Experimental Technology DSubsidence Control ft. ft. 1
II Geothermal(Closed Loop) DTracer '20.DRILLING LOG(attach additional sheets If necessary) -
R Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(c41ay hardness sowrock type,grata emu etc.)
0 ft. 18 n Red Clay
4.Date Wells)Completed:12/22/23 Well ID#397920 18 n 28 n Sandy Overburden ..... .....
fla.Well Location: 28 ft' 44 ft' Solid Rock C.. .„r p; i
Sharon Deal 55 ft• 60 ft• Vein
Facility/Owner Name Facility I D#(if applicable) 100 ft. 110 ft. Granite Variation ,bN I Z 2021
0 Miller Rd, Salisbury 28147 280 rt. 285 ft. Granite variation ,U;,,,;-R-4,,,i1 prr.� ,.ea BSI
Physical Addness,City,and Zip 400 ft• 410 ft• Granite variation DvvOi•_OQ
Rowan 474 009 21.-REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22 Ce cation: L...(2_,_
35 37 59.152 N 80 35 10.306 W
Li -Cl2j23
6.Is(are)the well(s)jPermanent or Temporary Signature of Certified Well Contractor 1 Date
By signing this form,I hereby cerh y that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or DNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out blown 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't SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft) 24a.For All Wells: Submit this i form within 30 days of completion of well
For multiple wells list all depths!'different(example-3@200'and 2(4)100) construction to the following: ,
10.Static water level below top of casing: ,-_-- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
61
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm)o Method of test:weir 1
24e For Witter Snp61V&Injection Wells: In addition to tending the form to
chlorine 1.7 lbs the address(es) above, also submii one copy of this form within 30 days of
13b.Disinfection type: Ammme 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