GW1-2021-02585_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 100 ft. 240ft 2 GPM
4449A 4 ft• 425 ft 5 GPM
NC Well Contractor Certification Number IS.OUTER CASING foe mutti-cased;wells ORLINER ifa ble
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
It- ft 61/41n SDR21 PVC
Company Name iG INNER CASING OR TUBING(Reothetmml closed-loop)
327510
2.Well Construction Permit#: FROM TO I 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): ft• ft in.
Water Supply Well: FROMCREE TO DIAMETER SLOTSIZF THICKNESS MATERIAL
Agricultural E]Municipal/Public 0 ft. ft. in.'
Geothermal(Heating/Cooling Supply) x®Residential Water Supply(single) ft g im
Industrial/Commercial Residential Water Supply(shared) I8.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ft- Holeplug Gravity 26
Monitoring r3Recovery ft. ft.
Injection Well: R. ft.
Aquifer Recharge OGroundwater Retitediation
lA SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ostormwater Drainage ft• ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 2Q DRILLING LOG attach additional sheets if
Geothermal Heatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color lurch soturveE a etc
ft. ft. Clay,
4.Date Well(s)Completed: 716/21 Well W#327510 ft 60 ft• Sandy Overburden
Sa.Well Location: 80 ft., `ft• weathered rock
John Matheson 89 ft 99 ft. solid roc
Facility/Owner Name Facility ID#(if applicable) 0 f- WE ft. soft/broken rock
765 Sunset Pointe Dr, Salisbury 28146 ft ft•
Physical Address.City,and Zip ft ft 1,
Rowan 6061­1003 21.REMARKS
County Parcel Identification No.(PIN)
C,Q J•.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `` v
(if well field one lat/long is sufficient) 22.Certification:
35 40 7.818 N 80 21 32.023 �i;
6.Is(are)the well(s):X�Permanent 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: E3Yes or EINo 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
construe on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft•) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 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 Inlection 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) 5 Method of test: Weir 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlorine 20 oZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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