GW1-2021-04650_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
S encer Adams �"� `�'� "p g, 1a.WATER ZONES l
Well Contractor Name ! PROM TO DESCRIMON
4449A 021 200 fL 245 iL 7 GPM'
�Vh A 1. 7 2 U ti111, ft. ft.
NC Well Contractor Certification Number r? of O{;SI(r 15.OUTER CASING for multi eased wells OR LINER if a livable
Rowan Well Drillin ,n., 3`'��' ` ;
g �9t1�t1�'R:�UI;v'S+'��'�� FROM ft. I TO ft, DLAMETERi� THICKNESS MATERIAL
Company Name 1' 0 75 6 1/4 SDR 21 PVC
354325 16.INNER CASING OR TDBING eothermal dosed-loo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable wen construction permits(i.e.UIC,County,State,Varfatrce,etc.) tL ft. io.
3.Well Use(check well use): tL ft. in.
Water Supply Well: 11 SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public 0 ft. fL in.
—)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) 19.GROUT
_11rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 4' Holeplug Gravity 13 bags
Monitoring E Recovery ft. ft.
Injection Well:
ft. [L_
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if livable
" Aquifer Storage and Recovery 0Salinity Barrier,._ FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage n- R•
Experimental Technology I Subsidence Control ft. ft.
:)Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional'sheets if necessary)
-Geothermal(Heatin Coolin Return) 00ther(explain under#21 Remarks) FROM I TO DESCRIPTION color hardness,soll/rock tyM grain size,etc.
0 g, 15 eft; Red Clay
4.Date Well(s)Completed:4/19/2 1 sell ID#354325 15 fL 40 ft- Sand'y Overburden
5a.Well Location: 40 ft' 65 rL Weathered Rock
Don McGee 65 ft. 75 It- Solid Rock
Facility/OwnerName Facility iD#'(ifapplicable) ft. rt.
585 Goodnight Rd, Salisbury 28147 IL ft.
Physical Address;City,and Zip ft. ft.
Rowan 768065 21.REMARKS,
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: i
35 39 33.379 N 80 35 39.101 W h_o,_ ' .- `--
6.Is(are)'the well(s)j9Permanent or Temporary Signatur of Certified Well Contractor Date
By signing this form,7 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or E)No with 15A A'CAC 02C.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 of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 i GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also,attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (it•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd different(example-31200'and 2@1001 construction to the following:
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 276994617
11.Borehole diameter:6 (in.) 24b.For Iniection 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
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc)
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)7 Method of test:Airlift 24c.For Water Suooly&Injection Wells: In addition to sending the form to
Chlorine 14 OZ the address(es) above, also submit Pone 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