GW1-2021-07969_Well Construction - GW1_20211122

Prinf Foam
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 44 WATER'ZONES.� -
Well Contractor Name FROM TO DESCRIPTION
4449-A 205 ft- 265 rL rcve
ft. ft.
NC Well Contractor Certification Number 15rxOUTER CASING foY.multi cased wells OR'=LOVER if a"`"'licable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 62 f 6 1/4 rn' SDR 21 PVC
Company Name r�
27.7649 �16 INNER'CASUVG OR'TUBDVG 'eothermal dosed-loop) *_^
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): fL ft. in.
e47.SCREEN'.',_,..�_ �. ' .,,
Water Supply Well: " `
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_!Agricultural []MunicipaUPublic ft. ft. in.
:]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL in.
IndustriaUCommercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. Holeplug Gravity 13 bags
Monitoring Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK"if a "Gcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -20 DRILLING LOG.attach additionst sheets if access _'-
_'Geothermal(Heating/Cooling Return) (explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soill o k s etc.
:Other 0 ft. 15 ft, day
4.Date Well(s)Completed: 10/8/21 Well ID#279649 15 ft. 52 fl' sand/weathered rode p
5a.Well Location:
52 ft. 82 ft. solid rock r—
Bull River Development ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. i
100 Middle Oaks Dr, Salisbury ft. fL DWR SECTION
Physical Address,City,and Zip ft. ft. (taT-l.'fl��ATION1 e:tnrPeghjG U✓` T
Rowan 606034 .2JitEnrARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 40 28.257 N 80 20 23.0866 W
to �8 l�l
6.Is(are)the well(s)fBPermanent or Temporary 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: E]Yes or E)No with 15A NCAC 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 an 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 9 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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.)
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, weir 24c. For Water SuDoly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: 11 oZ 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