GW1-2021-02604_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION'
57
4449A It. 240 ft- 2 GPMI
4 ft• 425 ft- 2 GPM
NC Well Contractor Certification Number 1&OUTER CASING for mold-cased welts OR LIlVER ff a
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft cL 6 114 m SDR21 PVC
Company Name 336252/JMB2269
iti.INNER CASING OR TUBING; eothrraial closed-1 `
2.Well Construction Permit A FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft•` ft. in.
3.Well Use(check well use): ft• tY 1n.
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public 0 ft; ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft ft• in
Industrial/Commercial E)Residential Water Supply(shared) IS.GROUT
iff i lion FROM TO MATERIAL EMPLACEMLNT METHOD&AMOUNT
Non-water Supply Well: 0ft- 57 ft. EZ!Seal Pump 12
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDlGRAVEL PACK.(ifapplicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft-
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if t
Geothermal Heatin Coolin Return Other a lain under#21 Remarks FROM To DESCRH'iTON r smv�g c l
ft- �• ay ann
4.Date Well(s)Completed: 7/12/21 Well ID#336252 ft. 57 ft- Solid Rock
Sa.Well Location: ft. ` ft.
Carolina Alpine �-
Facility/Owner Name Facility tD#(if applicable) ft' ft
190 Zeb St, Salisbury 28144 it. h. T v�
L
Physical Address,City,and zip ft-
fL C� G,0
Rowan 048 077 21.REMARKS o
County Parcel Identification No.(PIN)
l`tiQ�l�iL�3
5b.Latitude and longitude in degt ee5/mtnutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification:
35 43 11,400 N 80 24 5.515 W
6.Is(are)the well(ale)Permanent Permanent or OTemporary Signature ckCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.IS this a repair to an existing well: [)Yes or JMNo with 15A NCAC 02C.0100 or ISA NCAC 02C B200 Well Construction Standards and that a
If this is a repair,fill our 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:
S.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: 1 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 we(ts list all depths if different(example-1@200'and 1@100) 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 Serviee'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For iniection 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: 16M Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 4 Method of test: Weir 24c.For Water SapDly&Injection Wells: In addition to sending the form to
Chlorine 18 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 OW-1 North Carolina Department of Environnaental Quality-Division of Water Resources Revised 2-22-2016