GW1-2021-04665_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 4""r.J i s 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449A 1`�Ay ,� 7 2021 83 ft- 95 12 GPM
fL ft.
NC Well Contractor Certification Number -1ft. U111
15.OUTER CASING for multi-cased wells OR LINER if a livable
Rowan Well Drilling 't` �`1"�i l a Cr��YiOi3 FROM TO DIAMETER THICKNESS MATERIAL
0 ff• 83 fL 6118 SDR21 JPVC
Company Name
A�]A 16.INNER CASING OR T[1BRVG eothertnal closed-loop)30
2.Well Construction Permit#: 3934 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,IrartancA etc.) ft. ft. in.
3.Well Use(check well use): ft• ft, in.
Water Supply Well: %:17.SCREEN .,
FROM - TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. fL in.
Geothermal(Heating/Cooling Stipply) )Residential Water Supply(single) ft. ft. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
"llniRation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 '.. ff• Holeplug Gravity 12 bags
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK f a'livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStomuwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary),. _
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardtien,solUmek type,gnin size etc.
0 ft. 10 ft- Clay
4.Date Well(s)Completed:4/9/2 1. Weil fD#303934 10 ft• 55 H• Sandy Overburden
5a.Well Location: 55 ft• 73 It- Weathered/Broken Rock
Lillian Davis 73 ft. 83 fir- Solid Rock
Facility/Owner Name Facility ID#(if applicable)
124 Lauren Ln, Salisbury 28146
Physical Address,City,and Zip ft. ft.
Rowan 630A231 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certification:
35 35 4.898 N 80 24 17.186 W � 4 l 9 Iz l
6.ls(are)the well(s)ff)Permanent or Temporary Signs 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: E)Yes or ElNo with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
Ijrhis is a repair,fill out known welt construction information and explain the nature ofthe copy ofthis 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 I 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: 95 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenr(etample-3 200'and 2@1001 construction to the following:
811
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring,use"+" 1617 Mail Servici'Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection 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.)
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.Suew&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 8 OZ completion of well construction to the coup health department of the
13b.Disinfection type: Amount: p county ep county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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