GW1--01793_Well Construction - GW1_20240320

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14:WATERZONES;
FROM TO DESCRIPTION I '
Welt Contractor Name 144 300 2 GPM
4449-A 300 ft. 310 ft. 6 GPM
NC Well Contractor Certification Number 15 ODTERCASING(tor nrulti.aeed:weUU)ORLTNER(If an liable);':
Rowan Well Drilling FROM TO DIAMETER I ITHICINESS MATERIAL
0 ft. 144 8. 6 1/4" in', 0.188 Galvanized
Company Name ^ 16.1NNERCASING.OR TUBING.(geothermulclosed400p) .c: ;.:.' ...:.:: :'. :-.
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2.Well Construction Permit#: b FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State,Variance,etc.) ft• ft. In.,
ft.3.Well Use(check well use): ft. In.
Water.Sn Well:
PPIy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 0 R. ft. is
Geothermal(Heating/Cooling Supply) %°Residential Water Supply(single) ft ft In.
Industrial/Commercial °Residential Water Supply(shared) ie GROUT:::.` .•: . ::.::::':.
Irrigation FROM TO MATERIAL - EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Holeplug• Gravity
Monitoring °Recovery ft. ft.
Injection Well: ft ft,
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer '2a:DRILLING LOG(atteeh additional nheero'U ueoeseary). .. ....
PROM TO - DESCRIPIION.(eoior.hardness,soahoek type,grain aka,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft• 20 ft. clay j
4.Date Well(s)Compieted:2/5/24 Weil ID#389116 20 ft 100 t sandy overburden
Sa.Well Location: 100 t 134 ft weathered'rock ,,_,
1 o ;
David Newell 134 ft 144 ft solid rock '"4,, i,�rl i 14 i r:
Facility/Owner Name _. --- - - -Facility lD#(if applicable) 180 ft. 190 ft• brown rock MAR L r��
3330 Mt Hope church Rd, Salisbury 28146 300" 310 IVI
brown rock U
Physical Address,City,andZip ft' ft. trtfni Tt y4if,"1 ar-.. •r.Jj(iW3
Rowan 418 157 21 REMAR1 <::•••• ,_ r.:4, '` 771r�:.
County ParcelIdentificationNo.(PIN) top 4' plastic, 140'galavenizod
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 34 7.676 N 80 30 8.979 W �� I2�(I .
6.Is(are)the well(s)1x Permanent or Temporary Si of Certified Well Contractor Date
By signing this form,I hereby cent that the miffs)was(were)constructed in accordance
1.Is this Si repair to an existing well: °Yes or EjNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this le a repair,fill out brown well construction information and explain the nature of the copy ofthis 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 GeoprobeiDPT 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 I OW-1 is needed, Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface:325 (ft) 24a. 'or All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3®200'and 2(0100) 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 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter;6 (iw) 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: construction to the following: i
(i.e.auger,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)8 Method of test:weir 24c.For Water SPDDIE&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:15 OZ 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