GW1-2021-07974_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams
Well Contractor Name FROM TO DESCRIPTION
4449-A 97 ft. 345 rt. incur.+
fL fL
NC Well Contractor Certification Number 15.OUTER CASING:formul h easeAwells ORLINER ifa""ficatile
Rowan Well Drilling FROM TO DIAMETER THICIQVESS MATERIAL
0 ft. 97 ft' 6114 rn' SDR21 PVC
Company Name _ .,:..
.16.]INNER CASING OR TUBING eothermal cl
354166 osed-lao _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc) fL ft. is
3.Well Use(check well use): ft. ft. in.
47:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_11Agricultural nMunicipal/Public ft. fa in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. ire
_;IndustriaUCommercial DResidential Water Supply(shared) 18.'GROUT.
7il Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL Holeplug Gravity 14 bags
_ Monitoring Recovery ft. fL
Injection Well:
tL fL
Aquifer Recharge Groundwater Remediation hlr SAND/GRAVE
L`PAC1C ifa liable `.
Aquifer Storage and Recovery $alty BarrierFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. fL
:)Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .20.-DR1LLiNG.LOG(attach additioniitsheetsifnecessa"
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiVrock rain sae ere.
0 ft. 15 ft, day
4.Date Well s Completed: 10/7/21 Well ID#354166 15 ft. 60 ft.
p sandy overburden
5a.Well Location: W ft. 87 ft' weathered rock
Buller River Development 87 fL 97 fL solid rode
Facility/Owner Name Facility iD#(if applicable) fL ft.
720 White Crane Rd, Salisbury 28146
fL ft. ial
Physical Address,City,and Zip ft. fL Rowan 611 088 21.REMARKS County Parcel Identification No.(PIN) DVJR SEG UI'Ji.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
35. 40 14.890 N 80 20 37.890 W 19�� 1 D 1-7 )2,/
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6.Is(are)the well(s)ox Permanent or OTemporary Signature of Certified Well Contractor Date
13y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: 13Yes or )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 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') 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 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) 1/2 Method of test: Airift 24c. For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection type: Chlorine Amount: 16 oz
the address(es) above, also submit one copy of this form within 30 days of
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