GW1-2021-01703_Well Construction - GW1_20210323

1.Well Contractor lofortmation:
Spencer Adams 14.WATER ZONES
Well Contractor Name PROM to S rr R1Pr1ON
4449A h• h 1 GPM
m 41 «• 2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-casedwells OR LINER ifa kebk
Rowan Well Drilling mom TO DIAMETER TmCKNES4 MATERIAL
Company Name 0 ft. 1015 it. 6 114 1n. SDR21 PVC
333247 16 INNF3L CASING OR TUBING Tool closed-Too
2.Well COpSti•pCBOp Permit�`: FROM TO DIAMETER THICKNPSS MATERIAL
Lisr all applicable well construction permlta(i.e.U1C.County,State,Variance,etc,) ft. «. in.
3.Well Use(check well use): ft. I h. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 L n. is
Geothermal(Heating/Cooling Supply) R❑Rcsidential Water Supply),(single) g, N. 1n.
Industrial/Commercial QResidential Water Supply(shared) t&GROUT
IRI a[i0D FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water supply Well: «• ft. Holeplug raVity agS
Monitoring Recovery
rAquifier
pa ell:fer Recharge DGmundwater Remediati19.SAND/GRAVEL PACK IinhM Storage and Recovery QSalinity Barrier PRobt To MATERIAL EXIPLACEMENI'METHOD
Aquifer Test DStormwater Drainage h• «•
Experimental Technology DSubsidence Control
Geothermal(Closed loop) QTmcer 29.DRILLING LOG lattach additional sheets if access&
Geothermal (Heating/Cooling Rearm) E10ther(explain under#21 Remarks) FROM TO IDPSCRIPRON mbr, eolVroctt n ala Ne.
It. 30 R. Clay
4.Date Well(s)Completed: 2/4/2021 Well ID# 333247 «. 58 «. Weathered Rock/ Sand
so.Wen Location: 58 « h Solid Rock
Tony Brown ft. ft.
Facility/ ne Owr Name Facility ID#(ifapplirable) ft. ft. _
0 Sherrills Ford Rd, Salisbury 28147 h. R.
Physical Address,City,and Zip R. ft.
Rowan 459 258 21.REMARKS
County parcel Idenlificatum No.(PIN) k
Sh.Latitude and longitude in degrees/ednates/semuds or decimal degrees:
(if well field,one Iallong is sufficient) 2 .Certification:
35 40 18.098 N 8031 53.519
6.Islam)the well(s)OPerTamcent or OTemporary Signature ofCerlfied Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ONo with 15A NCAC 02C.DI00 or I5A NCAC 01C.02M Well Construction Standards and that a
1f 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 x21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPP or Closed-Loop Gmtherriial Wells having the same You may use the back of this page to provide additional well site details or well
constru on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of we116 construction details. You may also attach additional pages if necessary.
drillcd:l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft-) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple welh list all depths if different(erample�3@100'and 2@I00')
construction to the following:
l0.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use '. 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the forth 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:
o e.auger,rotary,cable,direct push,eat.)
FOR WATER SUPPLY WELLS ONLY: . Division of Water Resources,Underground lnjmtlon Control ProgrRm,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of Wsn Airlift 24c.For Water Supply&faiection Wells: In addition to sending the form to
Chlorine 18 OZ the addicss(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.