GW1-2021-04651_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: s�z
Spencer Adamst � ``� 14.WATERZONES h '
- PROM TO DESCRIPTION
Well Contractor Name
4449A ��A� 1 2021 123 11- 205 ft- 7 GPM j
uv�i 305 ft.
325 ft' 4 GPM;
NC Well Contractor Certification Number r+rn nSLCi,•
Rowan Well Drilling `iiiGtt�13�'rt ` �ii B FROUTERCTo formDIAEeTdEwellsOT.Fssa 1MA1TERIAL
0 ft• 123 ft• 61/4 i° SDR21 PVC
Company Name ����
16.INNER CASiNG OR TUBING(geothermal dosed-loo
2.Well Construction Permit#: 15 FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. IL in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. m,
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• Holeplug Gravity 21 bags
Monitoring E Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicsble
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DREMING LOG attach additional sheets if necessa
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color hard° solurock Baia size etc
0 fL 12 ft. Clay i
4.Date Well(s)Completed:4/20/21 Well ID#265115 12 IL 75 "IL Sandi Overburden
5a.Well Location: 75 ft- 113 ft• Weathered Rock
Joshua Brooks 113 ft' 123 ft• Solid Rock
Facility/Owner Name Facility iDN(ifapplicable) ft. ft.
325 Brandon Cole Dr, Salisbury,28147 ft. ft.
Physical Address,City,and Zip ft. ft.
Rowan 270 128 21.RENIARKs
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County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long insufficient) 22.Certification:
35 43 0.516 N 80 37 58.476 W
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6.Is(are)the well(s)@)Permanent or Temporary Signature of Certificd 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 [gNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair under N21 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:i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3t200'and 2@I00� construction to the following:
10.Static water level below top of casing:25 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above easing,use'•+•• 1617 Mall Service C I enter,Raleigh,NC 276994617
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
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) Method of test weir 24c.For Water Supnly&Injection_Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 15 OZ completion of well construction to the coup health department of the county
13b.Disinfection type: Amount where constructed. county p ty
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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