GW1-2021-04482_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD GW- �� For Internal Use Only:
1.Well Contractor Information:
Spencer Adams ,a.WATER zolvl
Well Contractor Name O(t�+ 0 FROM TO DESCRIPTION
4449A P (� 100 R 145 R 10 GPM
NC Well Contractor Certification Number ft. ft.�( Q
Rowan Well Drilling �(� 15.UUCERCASING for'malttcssedwells ORLINER Ga livable
FROM TO DIAMETER T*U(!: 'sR5 MATERIAL
Company Name o ft. 145 1 61/4 , in SDR21 JPVC
331 626 16.INNER CASING OR TUBING eotberm&I closed4ot
2.Well Construction Permit#: FROM TO DIAMETER -I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,Stahl Varionm etc. ft. it io-
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Pubtic 0 H. ft in
Geothermal(fieating/Cooling Supply) lResidential Water Supply single) ft ft. in.
Industrial/Commercial Residential Water Supply ishared) IS.GROUT
Irrigation I FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- _ 24 rt. Hoieplu Gravity 14
lGeothermal
onitoring Recovery ft R.
ction Well: tt.
quifer Recharge Groundwater Remediation 19:SANDJGRAVEL PACK ita Ikable quifer Storage and Recovery Salinity Barrier ( FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test Stotmwater Drainage titperimental Technology Subsidence Control it. ftothermal(Closed Loop) Tracer 20.DRILLIIVG:LOG attsch additionelsheets it neeesssFROM TO DESCRIPTION color haM soWrock n s1u,etc.(Heating/CoolingReturn Other(explain under#21 4—arks) rL it
4.Date Well(s)Completed.3/11/2021 Well JD#331626 22 e. 45 IL solid rock
5a.Well Location: ± 55 «. 85 ft• dirty veins water
Mark Jessop ft h.
Facility/Owner Name Facility ID#(ifapplicable) it. R•
200 Sapona Dr, Salisbury 28146 11 it It-
Physical Address,City,and zip R. ft
Rowan 50OA024 2t.REMARKS
County Parcel Identification No.(011N)
5b.Latitude and longitude in degrem/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 37 7.349 N 80 17 46.536 , W �
1 .� 3(II Iz►
6.Is(are)the well(s)Ox 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: ❑Yes or lNo with 1 SA NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the naav laf the copy ofthis record has been provided to the nee/l or+ner.
repair under 1111 remarks section or on the back ofthisform. 23.Site diagram Or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sa>kne You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of well construction details. You may also at additional pages if necessary.
drilled:f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 145 (D•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3Q200'and 1Q100) construction to the following.
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
1fisater We/is above casing,use"+' I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:624b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above,also submit one copy of this:form within 30 days of completion of well
12.Well construction method: Rotary 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: I 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 1 Method of test:Weir 24c.For Water Supply&Infection Wells: In addition to sending the form to
Chlorine 10 i 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 e county health department of the county
where constructed.
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Form©W-1 North Carolina Department of F�rnvironmental Quality-Division of Water Resources Revised 2-22-2016
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