GW1-2021-03181_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONE-S
Well Contractor Name FROM TO DESCRIPTION
4449A 225 rt 245 fL 9 GPM
ft. fL
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wetly OR LINER if livable
Rowan Well Drilling FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 rt N6 fL 61/4 i" SDR21 JPVC
16.INNER CASING OR TUBING eathermal closed-loo
352412
2.Well Construction Permit#: FROM TO W&METER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) rt• ft
3.Well Use(check well use): ft & in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaVPublic 0 ft ft. In.
Geothermal(HeatingtCooling Supply) OResidential Water Supply(single) ft ft. tn.
_ Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL Holeplug Gravity 23 bags
Monitoring DRecoverry ft. ft.
Injection Well:
ft tt.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK a llcable
Aquifer Storage and Recovery 13 Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft ft
Experimental Technology 13Subsidence Control ft tG
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCooling Return Other lain under#21 Remarks FROMI To DESC MMON color,hardness,soNrock tyM grains eta
0 fL 20 ft- Red Clay
4.Date Well(s)Completed:5/21/21 well Im#352412 20 rt 76 fL Sandy',Overburden
5a.Well Location: 76 ft 86 ft. Solid Rock
Loretta Meadows r�
Facility/Owner Name Facility ID#(if applicable) ft. ft. 9®
5755 Sherrills Ford Rd, Salisbury 28147 ft. r
Physical Address,City,and Zip R ft \(thj t1
Rowan 455039 21.REMARKS
County Parcel Identification No.(PIN) J( „ „N B J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 41 8.760 N 80 35 3.450 W
6.Is(are)the well(s)MPermanent or Temporary 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: ®Yes or E No with 1 SA NCAC 02C.0100 or 15.4 NCAC 62C.0100 Well Construction Standards and that a
If this is a repair,fill our 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 or on the back of this form.
23.Site diagram or additional well 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 UP 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@100) construction to the following:
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10.Static water level below top of easing:20 (fL) Division of Water Resources,Information Processing Unit,
If water 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
Rotary above,also submit one copy of this form within 30 days of completion of well
(ie Well construction method:ie.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)9 Method of test:Airift 24c.For Water Suaviv&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:Clorine Amount: 10 OZ 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
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