GW1-2021-04646_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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i.Well Contractor Information:
Spencer Adams s �„��%�t`� 14.WATER ZONES
Well Contractor Name 1 05 FROM TO DESCRIPTION
4449A ���Ay 7 2021 83 ft. 95 12 GPM
ft. r fLt.
NC Well Contractor Certification Number ^ �jt fpiSlrt U111 15.OUTER CASING for multi cased wells OR LINER if a 7icable
Rowan Well Drilling Company Name 0 83 « 61/8 i° I SDR21 JPVC
30 A�]A 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 393 F FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(1.e WC,County,State,Varhmce,etc.) ft. ft. in.
3.Well Use(check well use): D' R' in.
Water Supply Well: 17.SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Pubhc 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) g• ft. In,
Industrial/Commercial DResidential Water Supply(shared) GROUT
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0 rt- 20 , ft- Holeplug Gravity 12 bags
Monitoring DRecovery ft. ft.
Injection Well: '
ft. ft.
Aquifer Recharge []GroundwaterRemediation 19.SAND/GRAVEL PACK(if a 'licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage n
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return Other(explain under#Zl Remarks) FROM TO DESCRIPTION(color,hardo solYmck to size etc.
0 ft- 10 R- Clay'
4.Date Well(s)Completed:4/9/21 Well ID#303934 10 ft. 55 t ft. Sar4dy Overburden
5a.Well Location: 55 ft, 73 ft• Weathered/Broken Rock
Lillian Davis 73 ft• 83 R Solid Rock
Facility/Owner Name Facility ID#(if applicable)
124 Lauren Ln, Salisbury 28146
Physical Address,City,and Zip ft. ft.
Rowan 630A231 21.REMARK
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lo¢g is sufficient) 22.Certification: !��
35 35 4.898 N 80 24 17.186 W L4 19 I-L i
6.Is(are)the well(s)t)Permanent or Temporary Signa 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: C]Yes or ®No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided,to the well owner.
repair under 921 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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 95 00 24a. For All Wells: Submit this form within 30 days of completion of well
Ibr multiple wells list all depths ffdifferent(example-3 200'and 2C3a 100) construction to the following:
18"
10.Static water level below top of casing: (ft.) 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 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy ofjtbis form within 30 days of completion of well
12.Well construction method. construction to the following: j
(i.e.auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test:Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlorine 8 OZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constructio I 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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