GW1--01032_Well Construction - GW1_20240212

Print Form.
WELL CONSTRUCTION RECORD(GW 1) For Internal the Only: j
i
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Welt Contractor Name FROM TO DESCRIPTION
4449-A 240 fc 260 ft. 1 GPM
ft. ; ft.
NC Welt Contractor Certification Number !
15.OUTERCASING(forIDNti-easedwells)OR LINER Ora Itcable)
Rowan Well Drilling FROM TO ; DIAMETER ; THICKNESS „AIFRI„r.
Company Name 0 ft' 105 ft' 6114 ;' in. SDR21 PVC
404661 16.INNER CASING ORTUB)NG(geothermal doaeddoop)
2.Well Construction Permit#: FROM TO t DIAMETER - THICKNESS MATERIAL
Liu all applicable well construction penults(Le GIIC,County,State,Variance etc.) ffi 1 ft. in
3.Well Use(check well use): ft. 1fit. ! in.
WaterrSnpply Welk 17.SCREEN .
FROM TO i DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural °Municipal/Public 0 is ft. In.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) !R in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROu r
Irrigation FROM TO i MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20? R Holeplug Gravity 30 bags
Monitoring °Recovery ft. ! R ;,
Injection Well: .
ft. i ft.
Aquifer Recharge °GroundwaterRemediation '
feu Storage and Recovery {Salim Barrier 19 SAND/GRAVEL PACK(if applicable)
F+f tY FROM TO z MATERIAL EMPLACEMENT METHOD
Aquifer Test QStomlwater Drainage ft. i ft.
Experimental Technology °Subsidence Control ft. i ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(atacb additional abash if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(solar,Minims,aaatrrekt,pe,wainsiss.etc.
)
0 f 20 f Red Clay
4.Date Well(s)Completed:1/22/24 WellD#404661 20 ft. 50 ft• Sandy Overburden
Ss.Well Location: 50 Broken Rock
Cindy Stiller 95 ft. 105 ft• Solid Rock
Facility/OwnerName Faeih"tyID#(inapplicable) ft. ' ft. . . L`�i::t l�/��:7';
4645 Bringle Ferry Rd, Salisbury 28146 it. ft. •
Physical Address,.City,andT.rp ft. i ft. FEB 12 /O24
Rowan 608 211 21.REMARKS ,
County PaelIdentificatianNo.(PIN) I klnirr+:trivi-a�P.,a
n
Oe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 38 37.241 N 80 23 46.474 W ' A , t Iva 124
6.Is(are)the well(s)XPermanent or Temporary Si of Certified Well Contractor Date
By signing this fore,I hereby certify that the'wvll(s)was(acre)constructed in accordance
7.Is this a repair to an existing well: QYes or p%No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nat re ofthe copy of this record har'been provided to the'xell owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction detaiis.I You may also attach additional pages if necessary.
'
drilled:1 SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface:345 (ft.) 24a.For MI Wells: Submit this tam within 30 days of completion of well
For multiplexes list all depths ifdif era#(example-3Qa 200'and2Q100) construction to the following:
I
10.Static water level below top of casing: (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 NO 24b.For Inleedon Wells: In addition to sending the form to the address in 24a
Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test:weir 24c.For Water Supply&Infection 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:t;hlorine Amount: 16 oz completion of well construction to the county health department of the county
where constructed.
Fenn GW 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016