GW1-2022-00912_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams %IW'I'ATFRNES
O DESCRIPTION
Well Contractor Name5 fr.4449-A 5 R' SGMNC Well Contractor Certification Number SING for multi-cased wills OR INNER if a licableRowan Well Drilling O ril itt TER THICKNess MATERIAL
0 ft- 6114 IrL SDR21 PVC
Company Name
350689 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell constriction permits(i.e.111C,County,State,Variance,etc.) ft. ft is
3.Well Use(check well use): ft. fr. in
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipalIPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Olkesidential Water Supply(single) ft. ft,
I.. Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 40 ft. Holeplug Gravity 8 bags
:)Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge oGroundvater Remediation
19.SAND/GRAVEL PACK if applicable)
_.- Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
Aquifer Test E)Stormwater Drainage fr. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LAG attach additional shtets if necessary)
FROM TO DESCRIPTION color,hardness soil)—k rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. g0 tt. Clay
4.Date Well(s)Completed: 1217/21 Well ID#350689 30 ft• e0 ft. Sandy Overburden
rm ft. 90 ft. Solid Rode
Sa.Well Location:
George Saieg 110 ft. 118 ft- Dirty Vein r ;r::=
Facility ID# tf hcnble ft. ft ( „ "q rt
FacilitylOwner Name tY ( aPP )
465 Adrian Rd, Salisbury 28146 ft. ft. JAN l
ft. ft.
Physical Address,City,and Zip
Rowan 632AO28 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
35 35 3.875 N 80 23 41.651 W � L�
6.Is(are)the well(s)oPermanent or Temporary Signa ofCertified Well Contractor Date
BV signing this fitrm,I hereby certify that the rrell(s)rras(here)constructed in accordance
7.is this a repair to an existing well: []Yes or )No with 15A RCAC 02C.0100 or 15A A'CAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out knnvn well construction information and explain fire nature ofthe copy ofthis record has been provided to the well owner.
repair under_21 remarks section or an the back oJ'ihis form. 23.Site diagram or additional well details-
8.For GeoprobeIDPT 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 hells
construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 00 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdHferent(example-3@20I1'and 2 a 100') construction to the following:
10,Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If rraier level is above casing me"+" 1617 Mail Service 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) 7 Method of test: weir 24c. For Water Supply&Injection Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type:
Chlorine Amount: 19oz completion of well construction to the county health department of the county,
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016