GW1-2022-04487_Well Construction - GW1_20220509

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Spencer Adams 14,ZONES,, ..,
Well Contractor Nam FROM I TO DESCRIPTION
4449-A so ft. 1265 IL
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NC Well Contractor Certification ft. R Number 265 325 s GPM
1 OUTER CASING ernral mdvitibiOR°LINER'if
Rowan Well Drilling FROM To DrAMerER THIC►avess MATFRuu
CompWName 0 ft R 6114 SOR21 PVC
� 6<nrNERcaslNc'oR vsnvG imileroeed-lea ,
2.Well Construction Permit H 359956 FROM r
DIAMETER TIitCInUE56 MATERIAL
Lst all opplicable-11 cons...Wan permits(r e.WC County,State v,.j ce,etc.) & & in.
3.Well Use(check well on): ft �
Water Supply WtO: MSCREEN.,.
FROM I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural ©Municipal(Public &
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
ft R in
Industrial/Commercial DResidemial Water Supply(shared) ;it1:GROfIT
Irri lion FROM To MATERIAL.. EMINACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 M 20 ft HolePt+D Gravfty13
Monitoring 131tecovery fL ft.
lExperimental
ell• &quifer Recharge Groundwater Remediation
quifer Storage and Recovery Salinity BarrierFROM ToMATOmAL' BMP(ACEMENT ME180D
quifer Test OStorrawaterDrainage R Technology Subsidence Control R iL
eothermal(Closed loop) 13Tmcer :.10 111tIi U NGI OG aTO DESCREMONeothermal (Heating/Cooling Return Other lain under#21 Remarks FROM
ill ft ray
4.Date Well(s)Completed:4/29/22 wen W#359956 13 rL ro ft. Sandy ovettwraen
Sa.Well Location: o & 'm & Weathered Rack
Cornerstone 3 Properties m & err fL Soria Ro&
Facility/Owner Name Facility 09(if applicable) & R
1220 Pebble Point Rd,Salisbury 28146 ft ft.
Physical Address,City,and Zip R ft
Rowan 6060010 M KS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude to degrees/minates/sec onds or decimal degrees:
(ifwell field,one Wong is sufficient) ✓ rn"r _ '
22.Certification:
35 40 9.669 N 80 29 49.746 w
6.h(are)the weli(s)ox Permanent or OTemporary Signature ofCemfied well Contractor Date
By signing this form.I hereby certo that the weli(s)was(were)constructed in accordance
7.is this a repair to an existing well: QYes or MNo with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Stan wdr and that o
If this is a repair,fill out known well construction irrfornmtion and explain the nature ofthe copy of this record has been provided to are well owner.
repair wider#21 remarks section or on the bock ofthis form.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Imp 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 ifnecessary.
drilled:k SUBMITTAL INSTRUCTIONS
9.Total well depth below land solace: 325 (B.) 24a. For All Wei La Submit this form within 30 days of completion of well
For multiple wells list all depths ifdt,/jereni(esantple-3Q200'and 1@100) construction to the following:
10.Static water level below top of easiag: (tR) Dfiision of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-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-urger rotmy,cable,tired pusb.etc.) IL
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13s.Yield(gum)4 Method of test: Weir 24c.For Water Supply&Infection Welt: 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: 15°Z completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Departinent of Environmental Quality-Division of Water Resources Revised 2-22-2016
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