GW1--06200_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George Brown HI .14:WATERZONES = •i:.. .. •
Well Contractor Name FROM TO DESCRIPTION
4654A 160 ft. 180 tl. 5 GPM 1 , •
NC Well Contractor Certification Number
280 .ft. 300 '
•
10 GPM!
IS.OUTE&CASING(for multi-caetd:weBs ORLINEROf ap&able)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
CompanyName 0 24 6I(4 !�°. SDFi21P1/C
391556 .16.INNER CASING OR TUBING(geothermal cloeedloop) .
2.Well Construction Permit#: FROM TO DIAMETER . THICKNESS MATERIAL
List all applicable well cont tctionpermits(I.e.IIIC,County,State;Variance.etc.) ft. ft. ;by
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.6CRE13N. .
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ..
JJJ °Municipal/Public 0 • fL in' '
°Geothermal(Ileating/Cooling Supply) X°Residential Water Supply(single) ft, ft. in.
Industrial/Commercial °Residential Water Supply(shared) .
18:GROUT...'t ' . , :.
huigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 HOleplug GRavity 9 bags
Monitoring [ Re covery ft. ft.
Injection Well:
Aquifer Recharge °Giuundwatt Reinediation ft. ft 1
Aquifer Storage and Recovery Sit. . Barrier 19.SAND/GRAVEL PACK(ifapplcable)i : . ,• .
""nits FROM TO MATERIAL I EMPLACEMENT METHOD
°Aquifer Test °StonwaterDrainage ft. ft. i '
°Experimental Technology °Subsidence Control ft. ft. 1
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attacb additional'Sheets if neceisary) :.. .
°Geothermnal(Heating/Cooling Return) flOther(explain under#21 Remarks) FROM To DESCR sa7d6te mr,4 Waesr,ratltoet<typy unio are.eta)
O „� 9/13/24 391556 o `� 15 ft dirt/sad stone
4.Date Wells Co leted: Well m# 15 it. 24 solid rock
5a.Well Location: is ft.
Roger Chrysler ft. ft. ,_,-.i:—..'7.":,,
Facility/Owner Nameft e t b.. .J h.,.-? •r' s
A,.-.
Facility
ID#(if applicable) $.
399 Basinger Kluttz Rd, Salisbury ft ft.
OCT 9/, j_ 2024
Physical Address,City,and Zip ft. ft.
Rowan 421 001 .21:REMARKS -.lr;.7. „
i-faL'.. .'�Wi'
County Parcel Identification No.(PIN)
(,Yi.,;;.u'_3!�ti.i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/ong is sufficient)
35 56 5272 N 80 48 0538 W 22. rtifle ati°°`
j t �' /( 3 /z
6.Is(are)the well(s)lx Permanent or °Temporary `3ignetuuv of Certified Well q tractorn "' Date
By signing this form,I hereby cerf(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or X°No with 1SA NCAC 02C.0100 or ISA NCAC 01C.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 hay 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:l
SUBMITTAL INSTRUCTIONS i' '
9.Total well depth below land surface: 325 (ft) 24a.yor MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdiffere t(example-3@200'and 2®!00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If miter level Is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test:weir 24c.For Water Supply&Injection Wells: In addition to sending the form to
chlorine 15 oz the address(es) above, 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 GW-1 North Carolina Department of Environmental.Quality-Division of Water Resources Revised 2-22-2016