GW1-2022-04486_Well Construction - GW1_20220509

' fir„ P�int�Form
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 75 It. 105 fL ,GP„
235 fL 245 M .3 GM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER it cable
Rowan Well Drilling FROM TO DIAMETER TIDCKNESS MATERIAL
Company Name
0 ft 67 61/4 In SDR 21 PVC
3660,1 p 16.U4NER CASING OR TUBING eothermal closed-lomil
2.Well Construction Permit III: V V YV FROM TO DIAMETER TfntaavE.SS MATERIAL
List all applicable well construction permits fl.e.WC Colony,State,Yariance,etc.) it tL In.
3.Well Use(check well use): It. & in.
[Agricultural
r Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOTSITE THICiCNEESS MATERIAL
®MtmicipaVPublic tL & in.
thermal(Heating/Cooling Supply) L�fResidential Water Supply(single) fL ft. in.
ustrial/Commereial Residential Water Supply(shared) I&GROUT
tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 tt HOLEPLUG GRAVITY 14
:,)monitoring Recovery fL ft.
Injection Well:
fL fL
Aquifer Recharge ©Groundwater Remediation 19.SAND/GRAVEL PACK applies ble
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage IL fL
Experimental Technology 13Subsidence Control ft. fL
Geothermal(Closed Loop) QTracer 20.DRILLUYG LOG attach additional sheets Mneoe
Geothermal(HeatinglCooling Return Other lain under#21 Remarks FRO
0 M TO DESCBIMONcolor hardness,sofli a e eta)
20 ft CLAY
4.Date Well s)Completed:4/26/22 Well ID#366048 20 ft, 37 ft.
I
( p SANDY OVERBURDEN
5a.Well Location: n ft 57 fL WEATHERED ROCK
Tiffany Kravec 57 R 67 tc SOLID ROCK
Facility/Owner Name Facility ID#(if applicable) 76 fL a fL SOFT VEINS
'a
675 Timberland Trl, Salisbury 28147 ft fL
Physical Address,City,and Zip fL R
Rowan 462134 21.REMARKS
County Parcel Identification No.(PIN) ti. i S it i
5b.Latitude and longitude in degrees/minutestawnds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 39 18.113 N 80 32 38.179 W
6.hgare)the wens)oPermanent or [3Temporary Signatuie 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 wen: ®Yes or MNo with ISA NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repair,fill out k unm well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarka section or on the back of thisform.
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- 265 00 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©100'and 2 1001 construction to the following:
10.Static water level below top of casing: UP Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 276"-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: 1636 Man Service Center,Raleigh,NC 276"-1636
139.Yield(gpm) 7.5 Method of test:weir 24c.For Water Suooly&Infection Wells: In addition to sending the form to
the address(es) above, also submit:one copy of this form within 30 days of
13b.Disinfection type. chlorine Amount: completion of well construction to the county health department of the county
where constructed
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016