GW1--05949_Well Construction - GW1_20241009

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor information:
Spencer Adams .:14..WATER:zoNEs ;.-: i:;; .
FROM TO DESCRIPTION'
WellContractorName 44 ft. 340 It 1 GPM
4449-A 340 ft 400 ft. 2 GPM I
NC Well Contractor Certification NUmber .1LOIITERCASING(foemult(iiied*MIi)ORLINER'(itan Usable)' •• :
Rowan Well Drilling FROM TO DIAMETER
THICKNESS MATERIAL
0 ft. 44 ft. 61/4 ; L SDR21 PVC
Company Name 16.INNERCASINGOR•TIIBING(iteotherntJclosed400P) • :•:
403668 FROM TO DIAMETER THICKNESS MATERIAL
2.Well ConetracNon'Permit#: ft. ft. in.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)
3.Well Use(ch ft. ft �1u.eckwell use): - . . .
11.SCREEN. .
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural )MunicipallPublic 0 iz ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft In.
Industrial/Commercial Residential Water Su ty(shared)
Irrigation FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 - ffi 20 it Holeplug Gravity 20 .
Monitoring E3Recovery ft. ft
Injection Well: ft R.
uifer Recharge Groundwater Remediation
A4 `.19.SAND/GRAVEL PACK Of applicable)-> <:. :: `.': .. . . .
quifer Storage and Recovery .Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft I,
Experimental Technology OSubsidence Control ft. ft. 1:
Geothermal(Closed Loop) OTracer '30:DRILLING NAG(attich'add[f[onat eheiti it neeeaaar9)'.;,.:,.-:
FROM TO DESCRWTION(color,hardness,soWroetc tine,t�drq ems)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 30 ft. Clay/sand
4.Date Well(s)Completed:8/01/24 Well ID#403668 30 ft 44 ft* solid rock �. {
tan rock $`. ; /`
Sa.Well Location: 360 380 ft• tan rock ` r �'� .
Noel Burrell 0 C T 0 �' COZ4
Facility/Owner Name Facility InS(if applicable) ft. ft.
1170 Arabian Crossing Dr, Salisbury 28147 ft. ft• ir;l c,- --�r
Physical Address,City,and Zip ft ft. WV. &-;1
Rowan
421 203
County Parcel Identification No.-(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Qertlficatlon: I , ',
35 33 16.201 N 80 28 20.826 W —, f 1 (' 12 4
6.Ia(are)the well(s)4x Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: fjYes or DIt No with ISANCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known 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 oron the bocicof this form 23.Site diagram or additional well details:
S.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 details.You may also attach additional pages if necessary.
drilled:II tSUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface:405 (0) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3@200'and 2Qa I00') construction to the following. I
10.Static water level below top of easing: (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 On) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of tills form within 30 days of completion of well
12.Well construction method: construction to the following:
(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
i.
13a.Yield(gpm)3 Method of test:Weir 24c.For Water Supply&Infectlop 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: 19 OZ completion of well construction to the county health department of the county
where constructed.
Fern aW-1 North Carolina Department of F.nvironmental.tluality-.Division of Water Resources : Revised 2-22-2016