GW1-2021-07970_Well Construction - GW1_20211122

5 Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams _14."WATER
Well Contractor Name FROM TO DESCRIPTION
4449-A 114 I'L 285 ft. aces
290 IL 325 ft. xrcvM
NC Well Contractor Certification Number 45.OUTER CASING-fi rnu!fi-ciisid Ili.OR,L ER ali
We IN I
Rowan Well Drilling FROM I TO I DIAMETER THICKNESS 11!1�11,
0 ft, 114 fL 1 61/4 SDR 21 PVC
Company Name pl,`,_­"� �' �10117�
-46.WNERCASING OR TUBING(g6the dosed-loo ­
­ ��:' , .I
2.Well Construction Permit#: 337124 FROM TO DIAMETER i THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft ft. n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -717.SCREEN
FROM I TO I DIAMETER I SLOTSUE I THICKNMS I MATERIAL-
_; nMunicipaVPublic ft. & in.
(Heating/Cooling Supply) IgResidential Water Supply(single) f'. f, in
:)Industrial/Commercial [)Residential Water Supply(shared) -j&GROUT:
_)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fit- 20 ft. Holeplug Gravity 9 bags
DMonitoring pRecovery ft ft.
Injection Well: ft. ft.
:_3Aquifer Recharge [3Groundwater Remediation "19.SAND/GRA VEV-PACK if a-pplicable!:�,_
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. It, -J
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG:attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO _ DESCRIPTION(mlor,hardness,sWiProck type,gwmin size,etO
0 ft. 13 ft* red clay I i
4.Date Well Completed:8/30/21 Well ID#337124 13 IL 100 ff" sandy overburden
5a.Well Location: Im ft. 104 It. weathered rock
Tammy Barnhardt 104 ft- 114 ft* solid rock P ,re
I r
Facility/Owner Name Facility lD#(if applicable) ft. ft N—W
1020 0akl3luff Dr, Salisbury 28147 ft ft NOV 2 2
Physical Address,City,and Zip ft. ft
Rowan 458E004 A JUW,UVVK
County Parcel Identification No.(PIN) INFORMATION PROCESSING UNIT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35 40 13.291 N 80 33 8.903 W V136 I Z4-
6.Is(are)the well(s)oPermanent 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: []Yes or E)No with 15A NC4C 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 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 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: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftlifferem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: 15 00 Division of Water Resources,Information Processing Unit,
Ifivater level is above caving,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) 30 Method of test: Weir 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection type. Chlorine the address(es) above, also submit:one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016